Provider Demographics
NPI:1093815540
Name:DALEIDEN, ANN MARIE (NP)
Entity Type:Individual
Prefix:MS
First Name:ANN
Middle Name:MARIE
Last Name:DALEIDEN
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 1:350 30TH ST
Mailing Address - Street 2:SUITE 407
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3424
Mailing Address - Country:US
Mailing Address - Phone:510-419-0230
Mailing Address - Fax:
Practice Address - Street 1:350 30TH ST
Practice Address - Street 2:SUITE 407
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3424
Practice Address - Country:US
Practice Address - Phone:510-419-0230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP14287363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ07022ZOtherPTAN
CAQ24715Medicare UPIN
CA00G738960Medicare PIN