Healthcare Provider Details

I. General information

NPI: 1366563264
Provider Name (Legal Business Name): EILEEN MOFFITT CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 3RD ST VAMC SF DOWNTOWN CLINIC
SAN FRANCISCO CA
94107-1214
US

IV. Provider business mailing address

520 COVENTRY CT
VACAVILLE CA
95688-3601
US

V. Phone/Fax

Practice location:
  • Phone: 415-551-7309
  • Fax: 415-861-0323
Mailing address:
  • Phone: 707-447-2103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number000031173N2PNP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: