Basic Information
| Provider Information | |||||||||
| NPI: | 1023038130 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE LA FUENTE | ||||||||
| FirstName: | LISA | ||||||||
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| Credential: | C.N.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 254869 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958654869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168546975 | ||||||||
| FaxNumber: | 9168546864 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 SEAWOLF PSGE | ||||||||
| Address2: | |||||||||
| City: | CORTE MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949251823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152710979 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 11/19/2018 | ||||||||
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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 | 367A00000X | NMW1474 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.