MEDICARE: DESRON KALINE BOYD LVN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	VN221725	CA

General Provider Information

NPI Number	:	1508237348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESRON KALINE BOYD LVN

Provider Business Mailing Address
First Line	:	2254 PORT TRINITY CIR
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95206-4801
Country	:	US
Telephone Number	:	510-862-1057
Fax Number	:

Provider Business Practice Location Address
First Line	:	2254 PORT TRINITY CIR
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95206-4801
Country	:	US
Telephone Number	:	510-862-1057
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2015
Last Update Date	:	10/19/2015

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