MEDICARE: MS. CHRISTINE LACEDRA RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC1500X	Community Health Registered Nurse	RN 464023	CA
2	174H00000X	Health Educator

General Provider Information

NPI Number	:	1073068110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHRISTINE LACEDRA RN

Provider Business Mailing Address
First Line	:	13976 NW PALI ST
Second Line	:
City	:	SEAL ROCK
State	:	OR
Zip	:	97376-9417
Country	:	US
Telephone Number	:	541-272-0124
Fax Number	:

Provider Business Practice Location Address
First Line	:	13976 NW PALI ST
Second Line	:
City	:	SEAL ROCK
State	:	OR
Zip	:	97376-9417
Country	:	US
Telephone Number	:	541-272-0124
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2016
Last Update Date	:	08/18/2016

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