Healthcare Provider Details

I. General information

NPI: 1093190647
Provider Name (Legal Business Name): LANI CO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2015
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1156 FREMONT BLVD
SEASIDE CA
93955-5756
US

IV. Provider business mailing address

1156 FREMONT BLVD
SEASIDE CA
93955-5756
US

V. Phone/Fax

Practice location:
  • Phone: 831-899-8107
  • Fax: 831-899-8128
Mailing address:
  • Phone: 831-899-8107
  • Fax: 831-899-8128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number776887
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95006090
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: