Provider Demographics
NPI:1134494073
Name:DERICO, LAJUANA (RN)
Entity Type:Individual
Prefix:MS
First Name:LAJUANA
Middle Name:
Last Name:DERICO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 W LANCASTER BLVD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2305
Mailing Address - Country:US
Mailing Address - Phone:661-726-2630
Mailing Address - Fax:
Practice Address - Street 1:907 W LANCASTER BLVD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2305
Practice Address - Country:US
Practice Address - Phone:661-726-2630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-10
Last Update Date:2012-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA647897163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse