Provider Demographics
NPI:1508603069
Name:GANDARA, FAZIELA (NP)
Entity type:Individual
Prefix:
First Name:FAZIELA
Middle Name:
Last Name:GANDARA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12711
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658-5072
Mailing Address - Country:US
Mailing Address - Phone:949-542-0546
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 12711
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92658-5072
Practice Address - Country:US
Practice Address - Phone:949-542-0546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95025061163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice