Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0401X | Family Doctor - Addiction Medicine | CA |
NPI | 1205823077 |
---|---|
Provider Name | Susan Nylen |
First Address | Manteca, CA 95336-5900 |
Second Address | Manteca, CA 95336-5900 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/10/2005 |
Last Update Date | 21/02/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
23049 | (02) | CA |