Basic Information
| Provider Information | |||||||||
| NPI: | 1437781416 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEFELICE | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 ETHAN WAY STE 600 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958252296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164827623 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1508 ALHAMBRA BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958166510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166793590 | ||||||||
| FaxNumber: | 9164823647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2020 | ||||||||
| LastUpdateDate: | 02/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 95012354 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | 95012354 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.