Provider Demographics
NPI:1457998122
Name:PADFIELD, NELLY M (NP)
Entity Type:Individual
Prefix:
First Name:NELLY
Middle Name:M
Last Name:PADFIELD
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 1:6270 TERRACINA AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-6916
Mailing Address - Country:US
Mailing Address - Phone:760-508-6698
Mailing Address - Fax:
Practice Address - Street 1:200 S PARK RD STE 200
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8541
Practice Address - Country:US
Practice Address - Phone:909-297-6213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC55637208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
95012897OtherNP
95012897OtherFNP