Healthcare Provider Details

I. General information

NPI: 1396496808
Provider Name (Legal Business Name): SUSANA SO CHING CHAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2022
Last Update Date: 01/17/2022
Certification Date: 01/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 BANCROFT AVE
OAKLAND CA
94605-2403
US

IV. Provider business mailing address

33762 RYE TER
FREMONT CA
94555-1471
US

V. Phone/Fax

Practice location:
  • Phone: 510-828-4308
  • Fax:
Mailing address:
  • Phone: 510-828-4308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number462255
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number462255
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: