Healthcare Provider Details

I. General information

NPI: 1164970844
Provider Name (Legal Business Name): INXS M FIODEMBO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: INXS M CHANDLER

II. Dates (important events)

Enumeration Date: 09/12/2016
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

685 COLEMAN AVE
SAN JOSE CA
95110-2011
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 800-972-5547
  • Fax:
Mailing address:
  • Phone: 800-972-5547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN.361495
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95008817
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: