Healthcare Provider Details

I. General information

NPI: 1730017054
Provider Name (Legal Business Name): JACQUELYN BALENA EDRALIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2026
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 BEL AIR DR
VACAVILLE CA
95687-6337
US

IV. Provider business mailing address

256 BEL AIR DR
VACAVILLE CA
95687-6337
US

V. Phone/Fax

Practice location:
  • Phone: 707-310-0307
  • Fax:
Mailing address:
  • Phone: 707-310-0307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number692443
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: