Healthcare Provider Details

I. General information

NPI: 1083291637
Provider Name (Legal Business Name): JENNY IDICULA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2021
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR
SAN DIEGO CA
92103-9000
US

IV. Provider business mailing address

FILE 57326
LOS ANGELES CA
90074-7326
US

V. Phone/Fax

Practice location:
  • Phone: 800-926-8273
  • Fax: 888-539-8781
Mailing address:
  • Phone: 800-926-8273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1052820
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number860986
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA253034
License Number StateME
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95002777
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: