=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720638265
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROSITA JAMIL BRISTOL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2019
-----------------------------------------------------
Last Update Date | 09/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2690 GREAT HWY APT 101
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94116-2616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-769-9850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2690 GREAT HWY APT 101
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94116-2616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-769-9850
-----------------------------------------------------
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 | 698990
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------