Healthcare Provider Details

I. General information

NPI: 1114040029
Provider Name (Legal Business Name): MIMSIE M FARRAR N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3621 FOREST GLENN DR
MODESTO CA
95355-1339
US

IV. Provider business mailing address

3621 FOREST GLENN DR
MODESTO CA
95355-1339
US

V. Phone/Fax

Practice location:
  • Phone: 209-521-7411
  • Fax: 209-521-2640
Mailing address:
  • Phone: 209-521-7411
  • Fax: 209-521-2640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP12314
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: