Healthcare Provider Details

I. General information

NPI: 1295827426
Provider Name (Legal Business Name): CAROLE E. DEITRICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 GEARY BLVD 2 WEST, INSTITUTE ON AGING ASSESSMENT SERVICES
SAN FRANCISCO CA
94118-3347
US

IV. Provider business mailing address

194 SUSSEX ST
SAN FRANCISCO CA
94131-2935
US

V. Phone/Fax

Practice location:
  • Phone: 415-750-4111
  • Fax: 415-750-5341
Mailing address:
  • Phone: 415-476-1069
  • Fax: 415-476-8899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number176113
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: