Healthcare Provider Details

I. General information

NPI: 1285540906
Provider Name (Legal Business Name): GRACE LASATER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4077 FIFTH AVE
SAN DIEGO CA
92103-2105
US

IV. Provider business mailing address

1441 9TH AVE UNIT 707
SAN DIEGO CA
92101-8943
US

V. Phone/Fax

Practice location:
  • Phone: 858-832-2478
  • Fax:
Mailing address:
  • Phone: 951-376-6289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95341818
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: