=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184123820
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAT O CROSBY LVN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2018
-----------------------------------------------------
Last Update Date | 02/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2501 W EL SEGUNDO BLVD
-----------------------------------------------------
City | HAWTHORNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90250-3317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-310-1512
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2515 E OCEAN BLVD
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90803-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-310-1512
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164X00000X
-----------------------------------------------------
Taxonomy Name | Licensed Vocational Nurse
-----------------------------------------------------
License Number | VN212955
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------