Healthcare Provider Details

I. General information

NPI: 1396419198
Provider Name (Legal Business Name): LAWANA MARIE GREMILLION
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2751 NAPA VALLEY CORPORATE DR BLDG B
NAPA CA
94558-6216
US

IV. Provider business mailing address

2415 HORIZON LN APT 129
ANTIOCH CA
94509-2946
US

V. Phone/Fax

Practice location:
  • Phone: 707-227-3900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: