Provider Demographics
NPI:1063000727
Name:SAN PEDRO, ELEANOR LACSA (RN)
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:LACSA
Last Name:SAN PEDRO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:ELEANOR
Other - Middle Name:DELA CRUZ
Other - Last Name:LACSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:8725 STONY GLEN DR
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38133-2150
Mailing Address - Country:US
Mailing Address - Phone:662-402-0779
Mailing Address - Fax:
Practice Address - Street 1:7691 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3904
Practice Address - Country:US
Practice Address - Phone:901-516-6386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000294113163W00000X, 163WG0000X, 163WM0705X, 163WC0200X
MS894837163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163W00000XNursing Service ProvidersRegistered Nurse
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0000249113OtherREGISTERED NURSE
MS894837OtherREGISTERED NURSE