Provider Demographics
NPI:1174055875
Name:NAMBA, ERICA KANNA (DPT)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:KANNA
Last Name:NAMBA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3348 LA MESA DR
Mailing Address - Street 2:#2
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-4205
Mailing Address - Country:US
Mailing Address - Phone:225-802-4040
Mailing Address - Fax:
Practice Address - Street 1:125 SHOREWAY RD
Practice Address - Street 2:SUITE A
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-2788
Practice Address - Country:US
Practice Address - Phone:650-556-9420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA292837225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist