Healthcare Provider Details

I. General information

NPI: 1821819301
Provider Name (Legal Business Name): RENUKA RAJIV NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2024
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

949 PALM AVE
IMPERIAL BEACH CA
91932-1503
US

IV. Provider business mailing address

3620 3RD AVE UNIT 105
SAN DIEGO CA
92103-4126
US

V. Phone/Fax

Practice location:
  • Phone: 619-429-3733
  • Fax:
Mailing address:
  • Phone: 857-203-1905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF02240409
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95031599
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: