Healthcare Provider Details

I. General information

NPI: 1679164503
Provider Name (Legal Business Name): ASHLEY ANNE MIQUE LLANTADA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2021
Last Update Date: 02/02/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1922 THE ALAMEDA STE 425
SAN JOSE CA
95126-1453
US

IV. Provider business mailing address

3113 ROWE PL
FREMONT CA
94536-3541
US

V. Phone/Fax

Practice location:
  • Phone: 866-253-4268
  • Fax:
Mailing address:
  • Phone: 510-579-9658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: