Healthcare Provider Details

I. General information

NPI: 1700104007
Provider Name (Legal Business Name): STEPHANIE MARIA VANNICOLA MAGSANAY RN, MSN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 01/03/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 S MAIN ST
WALNUT CREEK CA
94596-5318
US

IV. Provider business mailing address

3340 ROMA PL
SAN RAMON CA
94583-3044
US

V. Phone/Fax

Practice location:
  • Phone: 415-295-4000
  • Fax:
Mailing address:
  • Phone: 925-829-4336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number672180
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18781
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: