Provider Demographics
NPI:1649949876
Name:MACIAS, ESTEFANIA DE JESUS (FNP)
Entity type:Individual
Prefix:
First Name:ESTEFANIA
Middle Name:DE JESUS
Last Name:MACIAS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3062 ASHTON ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-8801
Mailing Address - Country:US
Mailing Address - Phone:559-936-8135
Mailing Address - Fax:
Practice Address - Street 1:500 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-9693
Practice Address - Country:US
Practice Address - Phone:559-936-8135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018233363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner