Provider Demographics
NPI:1861671299
Name:GANDOLFO, CHRISTINA LYNN (RN)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINA
Middle Name:LYNN
Last Name:GANDOLFO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:CHRISTINA
Other - Middle Name:LYNN
Other - Last Name:CHACON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1167 E PAUL AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-4023
Mailing Address - Country:US
Mailing Address - Phone:559-447-8847
Mailing Address - Fax:
Practice Address - Street 1:1167 E PAUL AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-4023
Practice Address - Country:US
Practice Address - Phone:559-447-8847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA626247163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARVN004130OtherMEDI-CAL
CAEPS015920OtherMEDI-CAL