Healthcare Provider Details

I. General information

NPI: 1770951311
Provider Name (Legal Business Name): BLANCA CRUZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2015
Last Update Date: 09/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 SLAUSON AVE STE E
MAYWOOD CA
90270-4955
US

IV. Provider business mailing address

4332 HUNGERFORD ST
LAKEWOOD CA
90712-1139
US

V. Phone/Fax

Practice location:
  • Phone: 323-771-0080
  • Fax:
Mailing address:
  • Phone: 562-212-1420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95002485
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: