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General NPI Number Information
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NPI Number | 1548548357
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Entity Type | Individual
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Provider Name | JENELLE HELENE EZCURRA SANDY AUD
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Gender | Female
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Dates
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Enumeration Date | 07/27/2011
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Last Update Date | 03/22/2022
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Provider Practice Location Address
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Address Line | 2074 LAKE TAHOE BLVD
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City | SOUTH LAKE TAHOE
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State | CA
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Zip | 96150-6407
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Country | US
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Telephone | 530-318-4010
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Fax |
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Provider Business Mailing Address
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Address Line | 1285 APACHE AVE # 306
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City | SOUTH LAKE TAHOE
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State | CA
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Zip | 96155-7672
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Country | US
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Telephone | 530-318-4010
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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 | 231H00000X
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Taxonomy Name | Audiologist
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License Number | 147001386
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number | A3154
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License Number State | NV
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Taxonomy #3
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number | AU3526
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License Number State | CA
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