Provider Demographics
NPI:1114381936
Name:GUILLEN, EDNAGRACE (NP)
Entity Type:Individual
Prefix:
First Name:EDNAGRACE
Middle Name:
Last Name:GUILLEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:GUILLEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:12727 BRIAN CT
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-1117
Mailing Address - Country:US
Mailing Address - Phone:562-881-6545
Mailing Address - Fax:
Practice Address - Street 1:3050 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280
Practice Address - Country:US
Practice Address - Phone:323-357-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-07
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002989363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily