Healthcare Provider Details

I. General information

NPI: 1619510872
Provider Name (Legal Business Name): KARISMA EDERLYN AGUSTIN EBORA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2019
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
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: 760-499-3855
  • Fax: 760-499-3870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95012836
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95194733
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: