Basic Information
Provider Information | |||||||||
NPI: | 1477975860 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOLODRUBETZ | ||||||||
FirstName: | HIVA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SHAFA | ||||||||
OtherFirstName: | HIVA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 350 30TH ST | ||||||||
Address2: | #320 | ||||||||
City: | OAKLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 946093424 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5104656700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 350 30TH ST | ||||||||
Address2: | #320 | ||||||||
City: | OAKLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 946093424 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5104656700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/20/2014 | ||||||||
LastUpdateDate: | 08/27/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP2201X | RN2289237 | MA | N |   | Nursing Service Providers | Registered Nurse | Ambulatory Care | 363LF0000X | 95002980 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | 95070213 | CA | N |   | Nursing Service Providers | Registered Nurse |   |
No ID Information.