Healthcare Provider Details

I. General information

NPI: 1760832349
Provider Name (Legal Business Name): PHALACIA LINDELL BURTON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 BURT ST # 140
SANTA ROSA CA
95407-6223
US

IV. Provider business mailing address

240 BURT ST # 140
SANTA ROSA CA
95407-6223
US

V. Phone/Fax

Practice location:
  • Phone: 323-404-0705
  • Fax:
Mailing address:
  • Phone: 323-404-0705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number757957
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: