=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174388573
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ATTIEA BASSAM FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2024
-----------------------------------------------------
Last Update Date | 07/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1604 BLOSSOM HILL RD STE 10
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95124-6350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-528-8833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3400 STEVENSON BLVD APT J12
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94538-5812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-848-7318
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 95027522
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------