=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316001381
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIVINA GRACIA PANLASIGUI LU LVN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2006
-----------------------------------------------------
Last Update Date | 06/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1839 S EL DORADO ST
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95206-1305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-466-4200
-----------------------------------------------------
Fax | 209-466-4446
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3638 HENDRIX DR
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-817-5674
-----------------------------------------------------
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 | VN183039
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------