Healthcare Provider Details

I. General information

NPI: 1700393089
Provider Name (Legal Business Name): GRACIELA MEDRANO LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 01/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 LINCOLN AVE
PASADENA CA
91103-1324
US

IV. Provider business mailing address

18657 E ARROW HWY APT D
COVINA CA
91722-1854
US

V. Phone/Fax

Practice location:
  • Phone: 626-398-6300
  • Fax:
Mailing address:
  • Phone: 626-243-6023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number693753
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: