Provider Demographics
NPI:1972134047
Name:JOSE, PRINCE M
Entity Type:Individual
Prefix:
First Name:PRINCE
Middle Name:M
Last Name:JOSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 ASHFORD CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-8997
Mailing Address - Country:US
Mailing Address - Phone:404-680-0996
Mailing Address - Fax:
Practice Address - Street 1:1818 ASHFORD CT
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-8997
Practice Address - Country:US
Practice Address - Phone:404-680-0996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA751524163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse