Healthcare Provider Details

I. General information

NPI: 1588129183
Provider Name (Legal Business Name): JULIE DE JESUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2019
Last Update Date: 05/14/2021
Certification Date: 05/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N CHINA LAKE BLVD STE 190
RIDGECREST CA
93555-3131
US

IV. Provider business mailing address

1081 N CHINA LAKE BLVD
RIDGECREST CA
93555-3130
US

V. Phone/Fax

Practice location:
  • Phone: 760-499-3855
  • Fax: 760-499-3870
Mailing address:
  • Phone: 760-446-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95009965
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: