Healthcare Provider Details

I. General information

NPI: 1649793373
Provider Name (Legal Business Name): MICHELLE MONIQUE TILLETT-BUGGS LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 07/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 RAMONA EXPY
PERRIS CA
92571-7014
US

IV. Provider business mailing address

85 RAMONA EXPRESS WAY
RIVERSIDE CA
92531
US

V. Phone/Fax

Practice location:
  • Phone: 951-349-4195
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN685477
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: