Healthcare Provider Details

I. General information

NPI: 1184101693
Provider Name (Legal Business Name): DOREEN LATA KUMAR FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 12/30/2021
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 DALE RD
MODESTO CA
95356-9718
US

IV. Provider business mailing address

8755 HOLLOWSTONE WAY
SACRAMENTO CA
95828-5588
US

V. Phone/Fax

Practice location:
  • Phone: 209-735-3330
  • Fax:
Mailing address:
  • Phone: 916-212-0696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95053217
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95009130
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: