Basic Information
Provider Information | |||||||||
NPI: | 1194876284 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAMICO | ||||||||
FirstName: | LINDA | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BARTEK | ||||||||
OtherFirstName: | LINDA | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1510 4TH ST 1 | ||||||||
Address2: |   | ||||||||
City: | BERKELEY | ||||||||
State: | CA | ||||||||
PostalCode: | 947101717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5105258980 | ||||||||
FaxNumber: | 5105258982 | ||||||||
Practice Location | |||||||||
Address1: | 3603 CERRITO AVE | ||||||||
Address2: |   | ||||||||
City: | RICHMOND | ||||||||
State: | CA | ||||||||
PostalCode: | 948051761 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5102334854 | ||||||||
FaxNumber: | 5102334854 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/15/2007 | ||||||||
LastUpdateDate: | 08/05/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 13525 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
ID | Type | State | Issuer | Description | 514375 | 01 | CA | REG. NURSE LICENSE | OTHER | 13525 | 01 | CA | NP FURNISHING NO. | OTHER |