Provider Demographics
NPI:1962247676
Name:FIDELITY NURSING PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:FIDELITY NURSING PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:FIDEL
Authorized Official - Last Name:SEVILLA
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:209-470-8575
Mailing Address - Street 1:2004 AUTUMN OAK PL
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-4230
Mailing Address - Country:US
Mailing Address - Phone:209-470-8575
Mailing Address - Fax:
Practice Address - Street 1:2004 AUTUMN OAK PL
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-4230
Practice Address - Country:US
Practice Address - Phone:209-470-8575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No251J00000XAgenciesNursing Care