Healthcare Provider Details

I. General information

NPI: 1992010268
Provider Name (Legal Business Name): POONAM PRANITA CHANDRA N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 E BRIGGSMORE AVE
MODESTO CA
95355-2707
US

IV. Provider business mailing address

600 COFFEE RD
MODESTO CA
95355-4201
US

V. Phone/Fax

Practice location:
  • Phone: 209-550-4720
  • Fax:
Mailing address:
  • Phone: 209-521-6097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number19930
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNPF19930
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: