Healthcare Provider Details

I. General information

NPI: 1457695736
Provider Name (Legal Business Name): DE WAYNE D DELA GUERRA LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

928 N WESTERN AVE APT 306
LOS ANGELES CA
90029-3872
US

IV. Provider business mailing address

PO BOX 74654
LOS ANGELES CA
90004-0654
US

V. Phone/Fax

Practice location:
  • Phone: 619-793-9848
  • Fax: 323-544-0899
Mailing address:
  • Phone: 619-793-9848
  • Fax: 323-417-4865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN02498
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number240-636
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: