Healthcare Provider Details

I. General information

NPI: 1295566099
Provider Name (Legal Business Name): LERMA MALOMA DACASIN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2024
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 PARK SIERRA DR STE 208
RIVERSIDE CA
92505
US

IV. Provider business mailing address

3660 PARK SIERRA DR STE 203
RIVERSIDE CA
92505-3071
US

V. Phone/Fax

Practice location:
  • Phone: 951-687-2800
  • Fax: 951-687-7290
Mailing address:
  • Phone: 951-687-3400
  • Fax: 951-687-7630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95129009
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95031586
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: