Healthcare Provider Details

I. General information

NPI: 1609415728
Provider Name (Legal Business Name): ANGELIKA DESIMONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 04/09/2020
Certification Date: 04/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2907 CHANTICLEER AVE
SANTA CRUZ CA
95065-1815
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 831-423-4111
  • Fax:
Mailing address:
  • Phone: 831-447-2325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95013470
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: