Provider Demographics
NPI:1306456223
Name:FETALCO, KATE JEROMAE (FNP-BC)
Entity type:Individual
Prefix:
First Name:KATE JEROMAE
Middle Name:
Last Name:FETALCO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:KATE
Other - Middle Name:
Other - Last Name:FETALCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:555 E OCEAN BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-5084
Mailing Address - Country:US
Mailing Address - Phone:562-285-5050
Mailing Address - Fax:
Practice Address - Street 1:415 N PACIFIC COAST HWY STE 101
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-2840
Practice Address - Country:US
Practice Address - Phone:999-999-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015060363LF0000X, 363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care