Healthcare Provider Details

I. General information

NPI: 1306365366
Provider Name (Legal Business Name): NICOLE PUANANI INES CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6840 VIA DEL ORO STE 210
SAN JOSE CA
95119-1372
US

IV. Provider business mailing address

214 MYRTLE RD APT B
BURLINGAME CA
94010-3082
US

V. Phone/Fax

Practice location:
  • Phone: 408-284-2280
  • Fax:
Mailing address:
  • Phone: 808-250-7059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95007108
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: