Healthcare Provider Details

I. General information

NPI: 1790965218
Provider Name (Legal Business Name): KATHRYN S BEWICK PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 11/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 SCENIC DR BLDG.3
MODESTO CA
95350-6131
US

IV. Provider business mailing address

830 SCENIC DR BLDG.3
MODESTO CA
95350-6131
US

V. Phone/Fax

Practice location:
  • Phone: 209-558-6811
  • Fax: 209-558-8315
Mailing address:
  • Phone: 209-558-6811
  • Fax: 209-558-8315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberRN307606
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: