Healthcare Provider Details

I. General information

NPI: 1568248466
Provider Name (Legal Business Name): MS. JESSELLE GRACE LAGAO CARINO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2023
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 N BRENT ST
VENTURA CA
93003-2854
US

IV. Provider business mailing address

729 NAVITO WAY
OXNARD CA
93030-2583
US

V. Phone/Fax

Practice location:
  • Phone: 805-948-5011
  • Fax:
Mailing address:
  • Phone: 805-824-1022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95144687
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: