Healthcare Provider Details

I. General information

NPI: 1598198046
Provider Name (Legal Business Name): AYESHA CARITA OGUNNUPE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2013
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 37TH AVE 3RD FLOOR
SAN MATEO CA
94403-4324
US

IV. Provider business mailing address

PO BOX 53484
SAN JOSE CA
95153-0484
US

V. Phone/Fax

Practice location:
  • Phone: 408-375-1296
  • Fax:
Mailing address:
  • Phone: 408-375-1296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: