=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790590453
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MANJU PABLA LVN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2025
-----------------------------------------------------
Last Update Date | 02/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 494 BLOSSOM WAY
-----------------------------------------------------
City | CHERRYLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94541-1948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-582-7676
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16744 VICTORIAN TRL
-----------------------------------------------------
City | LATHROP
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95330-8835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-200-0320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 725035
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------