=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568213312
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KARA OLSEN THEIDING WHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2024
-----------------------------------------------------
Last Update Date | 03/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 AVINGTON RD
-----------------------------------------------------
City | ALAMEDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94502-6430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-846-0200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 AVINGTON RD
-----------------------------------------------------
City | ALAMEDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94502-6430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-846-0200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number | 95029359
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------