Basic Information
| Provider Information | |||||||||
| NPI: | 1194853622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CEFALO | ||||||||
| FirstName: | VIVIAN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | NMW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 COFFEE RD | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953554201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095241211 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1407 N TRACY BLVD | ||||||||
| Address2: | |||||||||
| City: | TRACY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953763445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095241211 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 07/01/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | NMW1509 | CA | Y | Other Service Providers | Midwife |
ID Information
| ID | Type | State | Issuer | Description | NP9791 | 01 | CA | NURSE PRACTITIONER LICENSE | OTHER |