Basic Information
| Provider Information | |||||||||
| NPI: | 1821474321 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANGEL | ||||||||
| FirstName: | LOURDES | ||||||||
| MiddleName: | DE GUZMAN | ||||||||
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| OtherLastName: | DE GUZMAN | ||||||||
| OtherFirstName: | LOURDES | ||||||||
| OtherMiddleName: | CARANTO | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2495 W MARCH LN STE 125 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952078224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094651080 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2495 W MARCH LN STE 125 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952078224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094651080 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2015 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 141126 | CA | N | Nursing Service Providers | Licensed Vocational Nurse | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.