Healthcare Provider Details

I. General information

NPI: 1811414428
Provider Name (Legal Business Name): JENNIFER LYNN REDWINE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 07/21/2022
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9890 COUNTY FARM RD STE 3
RIVERSIDE CA
92503-3678
US

IV. Provider business mailing address

9890 COUNTY FARM RD STE 3
RIVERSIDE CA
92503-3678
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-8320
  • Fax:
Mailing address:
  • Phone: 951-509-8320
  • Fax: 951-509-8333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN264991
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: