Basic Information
| Provider Information | |||||||||
| NPI: | 1316561228 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUFAULT | ||||||||
| FirstName: | MAEVE | ||||||||
| MiddleName: | ODILE JACKSON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26081 MOCINE AVE | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945442923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108815921 | ||||||||
| FaxNumber: | 5108815925 | ||||||||
| Practice Location | |||||||||
| Address1: | 26081 MOCINE AVE | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945442923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108815921 | ||||||||
| FaxNumber: | 5108815925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2020 | ||||||||
| LastUpdateDate: | 06/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | CA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.