Provider Demographics
NPI:1417253550
Name:DANNENBAUM, JEANNINE (NP)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:
Last Name:DANNENBAUM
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:PO BOX 5457
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93403-5457
Mailing Address - Country:US
Mailing Address - Phone:805-597-8386
Mailing Address - Fax:805-597-8353
Practice Address - Street 1:1100 PASEO CAMARILLO
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010
Practice Address - Country:US
Practice Address - Phone:805-484-8558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-08
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003911364SA2200X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ26NO10153900OtherLICENSE