Healthcare Provider Details

I. General information

NPI: 1285403998
Provider Name (Legal Business Name): MACIE ROSE ZAMUDIO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2023
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 BERN CT STE 130
SAN JOSE CA
95112-1242
US

IV. Provider business mailing address

1666 TRONA WAY
SAN JOSE CA
95125-5056
US

V. Phone/Fax

Practice location:
  • Phone: 408-437-8864
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number37922
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: