Provider Demographics
NPI:1477826105
Name:AZEVEDO, JEROME M (RN)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:M
Last Name:AZEVEDO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 FLORDIA AVENUE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95352-1032
Mailing Address - Country:US
Mailing Address - Phone:209-576-3880
Mailing Address - Fax:
Practice Address - Street 1:1441 FLORDIA AVENUE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-576-3880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA751358163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse