Provider Demographics
NPI:1124683008
Name:AFFOLTER, JOANNA KRISTINE
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:KRISTINE
Last Name:AFFOLTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOANNA
Other - Middle Name:KRISTINE
Other - Last Name:CLEMENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:24240 AWAHANEE RD
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-8333
Mailing Address - Country:US
Mailing Address - Phone:209-694-6004
Mailing Address - Fax:
Practice Address - Street 1:1904 RICHLAND AVE
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-4562
Practice Address - Country:US
Practice Address - Phone:209-300-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95053961163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95053961OtherREGISTERED NURSE