Healthcare Provider Details

I. General information

NPI: 1922819622
Provider Name (Legal Business Name): ANGELICA LYNETTE TELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2025
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 16TH ST # AT
MODESTO CA
95354-1119
US

IV. Provider business mailing address

920 16TH ST
MODESTO CA
95354-1119
US

V. Phone/Fax

Practice location:
  • Phone: 209-281-3644
  • Fax:
Mailing address:
  • Phone: 209-525-6155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-ZWYVKF
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: