Provider Demographics
NPI:1003310954
Name:PACKARD, IIESKA SHUNATEL (LVN)
Entity Type:Individual
Prefix:
First Name:IIESKA
Middle Name:SHUNATEL
Last Name:PACKARD
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4441 E KINGS CANYON RD
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93702-3604
Mailing Address - Country:US
Mailing Address - Phone:559-600-9171
Mailing Address - Fax:
Practice Address - Street 1:4441 E KINGS CANYON RD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3604
Practice Address - Country:US
Practice Address - Phone:559-600-9180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-23
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA691498164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse