Provider Demographics
NPI:1841466406
Name:TJANDRA, CORNELIA (FNP)
Entity type:Individual
Prefix:
First Name:CORNELIA
Middle Name:
Last Name:TJANDRA
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 1:5315 PACIFIC TERRACE CT
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94552-5539
Mailing Address - Country:US
Mailing Address - Phone:510-876-8110
Mailing Address - Fax:
Practice Address - Street 1:3300 COLLEGE DR BLDG 19
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-1698
Practice Address - Country:US
Practice Address - Phone:650-738-4270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR196275363LF0000X
CA17905363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABF513ZMedicare UPIN