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General NPI Number Information
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NPI Number | 1063889830
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Entity Type | Individual
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Provider Name | JENNIFER DELA VEGA ICASIANO RVS, BS
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Gender | Female
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Dates
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Enumeration Date | 08/28/2015
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Last Update Date | 08/28/2015
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Provider Practice Location Address
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Address Line | 333 SUNSET AVE STE 140
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City | SUISUN CITY
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State | CA
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Zip | 94585-2054
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Country | US
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Telephone | 707-334-1704
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Fax |
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Provider Business Mailing Address
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Address Line | 333 SUNSET AVE STE 140
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City | SUISUN CITY
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State | CA
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Zip | 94585-2054
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Country | US
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Telephone | 707-334-1704
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2471V0105X
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Taxonomy Name | Vascular Sonography Radiologic Technologist
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License Number | 00092881
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License Number State | CA
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