Healthcare Provider Details

I. General information

NPI: 1003098716
Provider Name (Legal Business Name): JEANEIL LARUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 DILLON DR
NAPA CA
94558-2307
US

IV. Provider business mailing address

3657 PARRETT AVE
NAPA CA
94558-2441
US

V. Phone/Fax

Practice location:
  • Phone: 707-253-2888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number621222
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: