MEDICARE: OPALYN P OLMEDO FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	NP95021752	CA

General Provider Information

NPI Number	:	1356064463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OPALYN P OLMEDO FNP-C

Provider Business Mailing Address
First Line	:	1415 RIDGEBACK RD STE 4
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91910-6983
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1415 RIDGEBACK RD STE 4
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91910-6983
Country	:	US
Telephone Number	:	619-421-4257
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2022
Last Update Date	:	09/22/2022

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