Healthcare Provider Details

I. General information

NPI: 1609445014
Provider Name (Legal Business Name): CASSIE GRAYDON LA BARREARE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4002 VISTA WAY
OCEANSIDE CA
92056-4506
US

IV. Provider business mailing address

595 LYNNETTE CIR
VISTA CA
92084-3724
US

V. Phone/Fax

Practice location:
  • Phone: 760-940-4055
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95017600
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: