Provider Demographics
NPI:1457427940
Name:UNTALAN, DORIS THERESE CRISOSTOMO (CNM)
Entity Type:Individual
Prefix:MRS
First Name:DORIS THERESE
Middle Name:CRISOSTOMO
Last Name:UNTALAN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MISS
Other - First Name:DORIS
Other - Middle Name:THERESE
Other - Last Name:CRISOSTOMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:2500 MERCED STREET
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4201
Mailing Address - Country:US
Mailing Address - Phone:510-454-1000
Mailing Address - Fax:
Practice Address - Street 1:2500 MERCED STREET
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4201
Practice Address - Country:US
Practice Address - Phone:510-454-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANMW 1079367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife