Healthcare Provider Details

I. General information

NPI: 1477227643
Provider Name (Legal Business Name): MAGDA CONSUELO SILVA LARA SOUZA DNP, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3124 INTERNATIONAL BLVD
OAKLAND CA
94601-2902
US

IV. Provider business mailing address

705 KATYDID CT
MARTINEZ CA
94553-2221
US

V. Phone/Fax

Practice location:
  • Phone: 510-434-5421
  • Fax:
Mailing address:
  • Phone: 650-888-7271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95011195
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: