Healthcare Provider Details

I. General information

NPI: 1336541481
Provider Name (Legal Business Name): BERTHA ALICIA LAGEOSE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BERTHA ALICIA ACOSTA NP

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 WESTWOOD PLZ PEDIATRIC INTENSIVE CARE UNIT, RRUCLA
LOS ANGELES CA
90095-8358
US

IV. Provider business mailing address

5533 SPANISH OAK LN UNIT E
OAK PARK CA
91377-3730
US

V. Phone/Fax

Practice location:
  • Phone: 310-267-7540
  • Fax:
Mailing address:
  • Phone: 818-991-9439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number9490
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: