Healthcare Provider Details

I. General information

NPI: 1871199539
Provider Name (Legal Business Name): HENRIETTA CHINASA ANIBUKO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVE # WARD93
SAN FRANCISCO CA
94110-3518
US

IV. Provider business mailing address

995 POTRERO AVE # WARD93
SAN FRANCISCO CA
94110-2859
US

V. Phone/Fax

Practice location:
  • Phone: 628-206-8412
  • Fax:
Mailing address:
  • Phone: 628-206-3364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number95214118
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95214118
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: