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General NPI Number Information
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NPI Number | 1386287753
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Entity Type | Organization
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Legal Business Name | SAN JOSE INTEGRATED CLINIC LLC
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Dates
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Enumeration Date | 10/17/2019
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Last Update Date | 10/17/2019
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Provider Practice Location Address
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Address Line | 2000 E JUAN SANCHEZ BLVD
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City | SAN LUIS
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State | AZ
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Zip | 85336-0481
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Country | US
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Telephone | 928-722-6098
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Fax | 928-627-0007
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Provider Business Mailing Address
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Address Line | 2575 W 24TH ST APT 168
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City | YUMA
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State | AZ
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Zip | 85364-6066
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Country | US
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Telephone | 928-722-6098
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | CLARISSE VANESSA NGUEHANANA
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Credential | FNP
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Telephone | 928-722-6098
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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