MEDICARE: ANTONIA DE LA ISLA BOLANOS LVN

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	164X00000X	Licensed Vocational Nurse	WV203250	CA

General Provider Information

NPI Number	:	1215493044
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTONIA DE LA ISLA BOLANOS LVN

Provider Business Mailing Address
First Line	:	5540 E LORENA AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93727-6330
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5540 E LORENA AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93727-6330
Country	:	US
Telephone Number	:	559-916-3104
Fax Number	:

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

Provider Enumeration Date	:	02/18/2019
Last Update Date	:	02/18/2019

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Directions to “ ANTONIA DE LA ISLA BOLANOS LVN” Practice Location

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