Provider Demographics
NPI:1669942538
Name:DARIYCHUK, INNA
Entity type:Individual
Prefix:
First Name:INNA
Middle Name:
Last Name:DARIYCHUK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5417 OLD ENGLAND CT
Mailing Address - Street 2:
Mailing Address - City:ANTELOPE
Mailing Address - State:CA
Mailing Address - Zip Code:95843-4675
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 HOWE AVENUE, SUITE 100
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825
Practice Address - Country:US
Practice Address - Phone:916-680-9510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006712363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMEDICAREMedicaid