Healthcare Provider Details

I. General information

NPI: 1770100950
Provider Name (Legal Business Name): DAPHNE MAE CARRIGAN LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2020
Last Update Date: 07/03/2020
Certification Date: 07/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11614 ANDERSON ST
LOMA LINDA CA
92354-3457
US

IV. Provider business mailing address

11614 ANDERSON ST
LOMA LINDA CA
92354-3457
US

V. Phone/Fax

Practice location:
  • Phone: 909-754-1128
  • Fax: 909-894-4700
Mailing address:
  • Phone: 909-754-1128
  • Fax: 909-894-4700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number150838
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: