Provider Demographics
NPI:1003019282
Name:FILLMORE, RONALD D (CRNFA)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:D
Last Name:FILLMORE
Suffix:
Gender:M
Credentials:CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6580
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-6580
Mailing Address - Country:US
Mailing Address - Phone:760-534-9550
Mailing Address - Fax:951-808-9700
Practice Address - Street 1:2776 PACIFIC AVE
Practice Address - Street 2:PACIFIC HOSPITAL OF LONG BEACH
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2613
Practice Address - Country:US
Practice Address - Phone:760-534-9550
Practice Address - Fax:951-808-9700
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA305990163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA305990OtherCRNFA LIC NUMBER