Basic Information
| Provider Information | |||||||||
| NPI: | 1073710398 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALIFORNIA DEPARTMENT OF CORRECTIONS &REHABILITATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21633 AVENUE 24 | ||||||||
| Address2: | |||||||||
| City: | CHOWCHILLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936100099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596656100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 21633 AVENUE 24 | ||||||||
| Address2: | |||||||||
| City: | CHOWCHILLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936100099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596656100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 02/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | WOODWARD | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 5596656100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | N.P. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | RN#452501 N.P.#8290 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 8004039 | 01 | CA | STATE ID # | OTHER |