Provider Demographics
NPI:1700145158
Name:SIDORI, DECIMAH MUTENDE (RN,)
Entity Type:Individual
Prefix:MRS
First Name:DECIMAH
Middle Name:MUTENDE
Last Name:SIDORI
Suffix:
Gender:F
Credentials:RN,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7950 FOOTHILLS BLVD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-6545
Mailing Address - Country:US
Mailing Address - Phone:916-781-2335
Mailing Address - Fax:
Practice Address - Street 1:7950 FOOTHILLS BLVD
Practice Address - Street 2:SUITE 170
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-6545
Practice Address - Country:US
Practice Address - Phone:916-781-2335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA630976163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse