Provider Demographics
NPI:1609264928
Name:GHANNAM, ANOULLA
Entity type:Individual
Prefix:
First Name:ANOULLA
Middle Name:
Last Name:GHANNAM
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 1:30 OCEAN GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-3734
Mailing Address - Country:US
Mailing Address - Phone:650-315-5421
Mailing Address - Fax:
Practice Address - Street 1:4331 PIEDMONT AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-4715
Practice Address - Country:US
Practice Address - Phone:650-315-5421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL8455174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist