MEDICARE: CHESTER G PROFETA BSN, MSN

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	4704420286	MI
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	846065	CA

General Provider Information

NPI Number	:	1548953458
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHESTER G PROFETA BSN, MSN

Provider Business Mailing Address
First Line	:	2571 SKYLARK DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95125-2942
Country	:	US
Telephone Number	:	714-588-6599
Fax Number	:

Provider Business Practice Location Address
First Line	:	2571 SKYLARK DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95125-2942
Country	:	US
Telephone Number	:	714-588-6659
Fax Number	:

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

Provider Enumeration Date	:	05/29/2023
Last Update Date	:	06/29/2026

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