Healthcare Provider Details

I. General information

NPI: 1962895797
Provider Name (Legal Business Name): LAILI FALATOONZADEH RN, CNM, WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 LAWS AVE
UKIAH CA
95482-6540
US

IV. Provider business mailing address

31723 HIGHWAY 128
CLOVERDALE CA
95425-9445
US

V. Phone/Fax

Practice location:
  • Phone: 707-468-1010
  • Fax:
Mailing address:
  • Phone: 909-260-6101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number95010469
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number236003
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95099659
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: