Healthcare Provider Details

I. General information

NPI: 1811626948
Provider Name (Legal Business Name): LAURA LYNN BIXBY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 06/06/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MOORPARK AVENUE
SAN JOSE CA
95128
US

IV. Provider business mailing address

751 CENTRAL PARK DR APT 3411
ROSEVILLE CA
95678-3530
US

V. Phone/Fax

Practice location:
  • Phone: 408-975-2730
  • Fax:
Mailing address:
  • Phone: 925-349-8288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number252158
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: