=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407428949
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA CABALCE CERVANIA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2021
-----------------------------------------------------
Last Update Date | 07/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2751 NAPPY VALLEY CORPORATE DRIVE, BLDG. B
-----------------------------------------------------
City | NAPA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-210-2437
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 319 FLAGSTONE CIR
-----------------------------------------------------
City | SUISUN CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94585-1799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-805-1400
-----------------------------------------------------
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 | 712250
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------