MEDICARE: DARRYL DE LOS ANGELES

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	364SG0600X	Gerontology Clinical Nurse Specialist	4457	CA

General Provider Information

NPI Number	:	1891339602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARRYL DE LOS ANGELES

Provider Business Mailing Address
First Line	:	8016 PASO ROBLES AVE
Second Line	:
City	:	LAKE BALBOA
State	:	CA
Zip	:	91406-1124
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8016 PASO ROBLES AVE
Second Line	:
City	:	LAKE BALBOA
State	:	CA
Zip	:	91406-1124
Country	:	US
Telephone Number	:	310-691-9146
Fax Number	:

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

Provider Enumeration Date	:	11/05/2019
Last Update Date	:	11/05/2019

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