=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760091201
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMARA MICHELLA ALTMAN NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2020
-----------------------------------------------------
Last Update Date | 08/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2542 S BASCOM AVE STE 100
-----------------------------------------------------
City | CAMPBELL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95008-5541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-913-2615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1620 SANTA CLARA DR STE 100
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-3559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-786-3750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 95018342
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | 844770
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------