Healthcare Provider Details

I. General information

NPI: 1366077323
Provider Name (Legal Business Name): NICOLE KATHLEEN BOERE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 COFFEE RD
MODESTO CA
95355-2803
US

IV. Provider business mailing address

1700 COFFEE RD
MODESTO CA
95355-2803
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-4500
  • Fax:
Mailing address:
  • Phone: 209-526-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95014091
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: