Healthcare Provider Details

I. General information

NPI: 1073261343
Provider Name (Legal Business Name): BRIDGETT LARHONDA LILLY LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 03/15/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2076 MAGNOLIA AVE APT 3
LONG BEACH CA
90806-4642
US

IV. Provider business mailing address

2076 MAGNOLIA AVE APT 3
LONG BEACH CA
90806-4642
US

V. Phone/Fax

Practice location:
  • Phone: 562-449-5172
  • Fax:
Mailing address:
  • Phone: 562-449-5172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN208954
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: