Provider Demographics
NPI:1578804340
Name:DEARDORFF, NATHANAEL (PMHNP-BC, PHN, RN)
Entity type:Individual
Prefix:MR
First Name:NATHANAEL
Middle Name:
Last Name:DEARDORFF
Suffix:
Gender:M
Credentials:PMHNP-BC, PHN, RN
Other - Prefix:
Other - First Name:NATE
Other - Middle Name:
Other - Last Name:DEARDORFF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN, PHN
Mailing Address - Street 1:931 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-4543
Mailing Address - Country:US
Mailing Address - Phone:530-621-6182
Mailing Address - Fax:
Practice Address - Street 1:931 SPRING ST
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-4543
Practice Address - Country:US
Practice Address - Phone:530-621-6182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95032485363LP0808X
CA95206418163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty