MEDICARE: MRS. CHRISTINA LYNN GANDOLFO RN

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	163W00000X	Registered Nurse	626247	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RVN004130	OTHER	CA	MEDI-CAL
2	EPS015920	OTHER	CA	MEDI-CAL

General Provider Information

NPI Number	:	1861671299
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHRISTINA LYNN GANDOLFO RN

Provider Business Mailing Address
First Line	:	1167 E PAUL AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93710-4023
Country	:	US
Telephone Number	:	559-447-8847
Fax Number	:

Provider Business Practice Location Address
First Line	:	1167 E PAUL AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93710-4023
Country	:	US
Telephone Number	:	559-447-8847
Fax Number	:

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

Provider Enumeration Date	:	11/02/2007
Last Update Date	:	11/02/2007

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