Provider Demographics
NPI:1306365366
Name:INES, NICOLE PUANANI (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:PUANANI
Last Name:INES
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 MYRTLE RD APT B
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3082
Mailing Address - Country:US
Mailing Address - Phone:808-250-7059
Mailing Address - Fax:
Practice Address - Street 1:6840 VIA DEL ORO STE 210
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1372
Practice Address - Country:US
Practice Address - Phone:408-284-2280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95007108363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics