Provider Demographics
NPI:1124601315
Name:GRADILLA, GENEVIEVE (LVN)
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:
Last Name:GRADILLA
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 1:18612 SANTA ANA AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:92316-2639
Mailing Address - Country:US
Mailing Address - Phone:909-421-7120
Mailing Address - Fax:
Practice Address - Street 1:10001 COUNTY FARM RD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3507
Practice Address - Country:US
Practice Address - Phone:909-421-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN184950101YM0800X
CA184950164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health