Healthcare Provider Details

I. General information

NPI: 1215333927
Provider Name (Legal Business Name): MADISON NICOLE FANDEL N.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2014
Last Update Date: 04/25/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 PALMETTO AVE STE A
PACIFICA CA
94044-2274
US

IV. Provider business mailing address

1305 PALMETTO AVE STE A
PACIFICA CA
94044-2274
US

V. Phone/Fax

Practice location:
  • Phone: 650-501-9397
  • Fax: 855-952-2441
Mailing address:
  • Phone: 650-501-9397
  • Fax: 855-952-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNT60518150
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberND858
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: