Provider Demographics
NPI:1538333984
Name:POPE, ETHELENE
Entity type:Individual
Prefix:
First Name:ETHELENE
Middle Name:
Last Name:POPE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 CROCKER DR APT 101
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95111-4367
Mailing Address - Country:US
Mailing Address - Phone:650-617-0580
Mailing Address - Fax:650-617-0587
Practice Address - Street 1:795 WILLOW RD BLDG 323-A
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-2539
Practice Address - Country:US
Practice Address - Phone:650-617-0580
Practice Address - Fax:650-617-0587
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA4481076171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator