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General NPI Number Information
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NPI Number | 1700766748
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Entity Type | Individual
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Provider Name | JAMIE DETELS LVN
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Gender |
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Dates
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Enumeration Date | 09/02/2025
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Last Update Date | 09/02/2025
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Provider Practice Location Address
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Address Line | 1687 YULUPA AVE
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City | SANTA ROSA
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State | CA
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Zip | 95405-7778
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Country | US
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Telephone | 707-546-6183
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Fax | 707-528-8027
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Provider Business Mailing Address
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Address Line | 1609 DEL ORO CIR
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City | PETALUMA
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State | CA
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Zip | 94954-5728
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Country | US
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Telephone | 707-393-7778
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164X00000X
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Taxonomy Name | Licensed Vocational Nurse
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License Number | 725390
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License Number State | CA
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