Healthcare Provider Details

I. General information

NPI: 1063087047
Provider Name (Legal Business Name): ALICEANNE THONDU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2021
Last Update Date: 05/23/2021
Certification Date: 05/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 PLACER ST
REDDING CA
96001-1170
US

IV. Provider business mailing address

5463 CLERMONT CT
WESTLAKE VILLAGE CA
91362-7173
US

V. Phone/Fax

Practice location:
  • Phone: 530-246-5710
  • Fax:
Mailing address:
  • Phone: 619-663-7293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95017260
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: