Healthcare Provider Details

I. General information

NPI: 1629550454
Provider Name (Legal Business Name): SOPHIA HELEN NOGUE RN, NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3451 E 12TH ST
OAKLAND CA
94601-3463
US

IV. Provider business mailing address

PO BOX 22210
OAKLAND CA
94623-2210
US

V. Phone/Fax

Practice location:
  • Phone: 510-535-3500
  • Fax: 510-535-4187
Mailing address:
  • Phone: 510-535-4000
  • Fax: 510-535-4189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95069697
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95007547
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: