Provider Demographics
NPI:1164970844
Name:FIODEMBO, INXS M
Entity Type:Individual
Prefix:
First Name:INXS
Middle Name:M
Last Name:FIODEMBO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:INXS
Other - Middle Name:M
Other - Last Name:CHANDLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:800-972-5547
Mailing Address - Fax:
Practice Address - Street 1:685 COLEMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110-2011
Practice Address - Country:US
Practice Address - Phone:800-972-5547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.361495363LF0000X
CANP95008817363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily