Healthcare Provider Details

I. General information

NPI: 1467077594
Provider Name (Legal Business Name): LERIN MORIAH JARACZEWSKI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3618 S PARKER ST
SAN PEDRO CA
90731-6462
US

IV. Provider business mailing address

3618 S PARKER ST
SAN PEDRO CA
90731-6462
US

V. Phone/Fax

Practice location:
  • Phone: 310-909-4959
  • Fax:
Mailing address:
  • Phone: 310-909-4959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP1700X
TaxonomyPerinatal Registered Nurse
License Number687045
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number687045
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number687045
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: