Healthcare Provider Details

I. General information

NPI: 1962247676
Provider Name (Legal Business Name): FIDELITY NURSING PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2024
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2004 AUTUMN OAK PL
STOCKTON CA
95209-4230
US

IV. Provider business mailing address

2004 AUTUMN OAK PL
STOCKTON CA
95209-4230
US

V. Phone/Fax

Practice location:
  • Phone: 209-470-8575
  • Fax:
Mailing address:
  • Phone: 209-470-8575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RICHARD FIDEL SEVILLA
Title or Position: NURSE PRACTITIONER
Credential: NURSE PRACTITIONER
Phone: 209-470-8575