Healthcare Provider Details

I. General information

NPI: 1538779020
Provider Name (Legal Business Name): GRACE LUMENARIO CECILIO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2020
Last Update Date: 08/09/2020
Certification Date: 08/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GEORGE BAILEY DETENTION FACILITY 446 ALTA RD STE 5300
SAN DIEGO CA
92158-0001
US

IV. Provider business mailing address

5757 LAKE MURRAY BLVD APT 89
LA MESA CA
91942-2208
US

V. Phone/Fax

Practice location:
  • Phone: 619-661-2789
  • Fax:
Mailing address:
  • Phone: 619-892-6279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number695643
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: