Basic Information
| Provider Information | |||||||||
| NPI: | 1811250236 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROPHETT | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5300 ANGELES VISTA BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232954555 | ||||||||
| FaxNumber: | 3232953021 | ||||||||
| Practice Location | |||||||||
| Address1: | 5300 ANGELES VISTA BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232954555 | ||||||||
| FaxNumber: | 3232953021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2012 | ||||||||
| LastUpdateDate: | 06/20/2012 | ||||||||
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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 | 163W00000X | RN507420 | CA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.