Provider Demographics
NPI:1023210739
Name:WARDA, FANTINE (NP)
Entity Type:Individual
Prefix:MS
First Name:FANTINE
Middle Name:
Last Name:WARDA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2803
Mailing Address - Country:US
Mailing Address - Phone:209-526-4500
Mailing Address - Fax:209-572-7901
Practice Address - Street 1:1700 COFFEE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2803
Practice Address - Country:US
Practice Address - Phone:209-526-4500
Practice Address - Fax:209-572-7901
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14939363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ07331ZMedicare PIN