Provider Demographics
NPI:1285046557
Name:MOGHADDAM, AMENNAH S (NP)
Entity type:Individual
Prefix:
First Name:AMENNAH
Middle Name:S
Last Name:MOGHADDAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AMENEH
Other - Middle Name:S
Other - Last Name:MOGHADDAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4361 RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-6611
Mailing Address - Country:US
Mailing Address - Phone:925-462-1755
Mailing Address - Fax:
Practice Address - Street 1:4361 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-6611
Practice Address - Country:US
Practice Address - Phone:925-462-1755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000419363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner