Healthcare Provider Details

I. General information

NPI: 1922582832
Provider Name (Legal Business Name): ANNA JADWIGA HADILAKSONO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 CARMEN LN
SANTA MARIA CA
93458-7729
US

IV. Provider business mailing address

128 LA COLIMA
PISMO BEACH CA
93449-2841
US

V. Phone/Fax

Practice location:
  • Phone: 805-928-7361
  • Fax:
Mailing address:
  • Phone: 732-754-3197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95010045
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: