1558911123 NPI number — GRACE M LOMIBAO MSN, RN, AGACNP-BC

Table of content: GRACE M LOMIBAO MSN, RN, AGACNP-BC (NPI 1558911123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558911123 NPI number — GRACE M LOMIBAO MSN, RN, AGACNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOMIBAO
Provider First Name:
GRACE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSN, RN, AGACNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MADRIGAL
Provider Other First Name:
GRACE
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1558911123
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8700 BEVERLY BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST HOLLYWOOD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90048-1804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13517 BROWNING PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA PUENTE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91746-1968
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-258-8758
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/16/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  95012594 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com