Basic Information
| Provider Information | |||||||||
| NPI: | 1568992402 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRACIDA | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | KAREN | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2610 INDUSTRY WAY | ||||||||
| Address2: | |||||||||
| City: | LYNWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902624283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106318004 | ||||||||
| FaxNumber: | 3106315875 | ||||||||
| Practice Location | |||||||||
| Address1: | 2640 INDUSTRY WAY | ||||||||
| Address2: | |||||||||
| City: | LYNWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902624284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106318004 | ||||||||
| FaxNumber: | 3106315875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2017 | ||||||||
| LastUpdateDate: | 06/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.