Healthcare Provider Details

I. General information

NPI: 1124639224
Provider Name (Legal Business Name): AMALIA RACCA RACIMO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1433 PASEO VERA ST
CARSON CA
90745-5600
US

IV. Provider business mailing address

1433 PASEO VERA ST
CARSON CA
90745-5600
US

V. Phone/Fax

Practice location:
  • Phone: 310-344-2279
  • Fax:
Mailing address:
  • Phone: 310-344-2279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95013713
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: