Healthcare Provider Details

I. General information

NPI: 1649717539
Provider Name (Legal Business Name): MARY BALLESTEROS LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2017
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 N FAIR OAKS AVE STE 200
PASADENA CA
91103-1620
US

IV. Provider business mailing address

455 W MONTANA ST
PASADENA CA
91103-1327
US

V. Phone/Fax

Practice location:
  • Phone: 626-398-6300
  • Fax: 626-398-5948
Mailing address:
  • Phone: 626-398-6300
  • Fax: 626-398-5948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN 248878
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: