Healthcare Provider Details

I. General information

NPI: 1942434089
Provider Name (Legal Business Name): ADRIENNE ROSE VERA-MAHAFFEY IDMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ADRIENNE ROSE MAHAFFEY IDMT

II. Dates (important events)

Enumeration Date: 05/04/2009
Last Update Date: 05/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

IV. Provider business mailing address

3267 PALOMINO CIR
FAIRFIELD CA
94533-7227
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-5395
  • Fax: 707-423-5426
Mailing address:
  • Phone: 707-423-5395
  • Fax: 707-423-5426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: