Healthcare Provider Details

I. General information

NPI: 1891228011
Provider Name (Legal Business Name): RUTH EMMA RALEIGH REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 W MONTANA ST
PASADENA CA
91103-1327
US

IV. Provider business mailing address

1610 SOUTH MAYFLOWER AVENUE UNIT C
MONROVIA CA
91016
US

V. Phone/Fax

Practice location:
  • Phone: 626-993-1222
  • Fax: 626-486-9693
Mailing address:
  • Phone: 818-515-6436
  • Fax: 626-357-9832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number416377
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: