Healthcare Provider Details

I. General information

NPI: 1417628173
Provider Name (Legal Business Name): PRICILLA ADELIA REQUENA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2021
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11118 S OSAGE AVE APT 7
INGLEWOOD CA
90304-2967
US

IV. Provider business mailing address

11118 S OSAGE AVE APT 7
INGLEWOOD CA
90304-2967
US

V. Phone/Fax

Practice location:
  • Phone: 424-581-2844
  • Fax: 424-581-2844
Mailing address:
  • Phone: 424-581-2844
  • Fax: 424-581-2844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberNON
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number123765
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: