Healthcare Provider Details

I. General information

NPI: 1053802579
Provider Name (Legal Business Name): KADIATOU DAFNEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2018
Last Update Date: 12/06/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 AVOCADO AVE STE 106
PERRIS CA
92571-2605
US

IV. Provider business mailing address

15488 CLEVELAND DR
FONTANA CA
92336-3181
US

V. Phone/Fax

Practice location:
  • Phone: 951-858-2118
  • Fax:
Mailing address:
  • Phone: 909-641-3539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNPF95008242
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: