Healthcare Provider Details

I. General information

NPI: 1174021521
Provider Name (Legal Business Name): CHARINA GELLACO QUIAMBAO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2018
Last Update Date: 03/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 FLORIDA AVE
MODESTO CA
95350-4437
US

IV. Provider business mailing address

1910 CUSTOMER CARE WAY
ATWATER CA
95301-5167
US

V. Phone/Fax

Practice location:
  • Phone: 209-492-7150
  • Fax:
Mailing address:
  • Phone: 209-384-6488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95008419
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: