Healthcare Provider Details

I. General information

NPI: 1841944550
Provider Name (Legal Business Name): AMANDA RENEE PELLEGRINO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1965 LIVE OAK BLVD
YUBA CITY CA
95991-8850
US

IV. Provider business mailing address

1965 LIVE OAK BLVD
YUBA CITY CA
95991-8850
US

V. Phone/Fax

Practice location:
  • Phone: 530-822-7209
  • Fax:
Mailing address:
  • Phone: 530-822-7209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: