Provider Demographics
NPI:1275030843
Name:MESEROLE, DOUGLAS CLAYTON (LVN)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:CLAYTON
Last Name:MESEROLE
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 S SUNSHINE AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-7554
Mailing Address - Country:US
Mailing Address - Phone:619-560-3196
Mailing Address - Fax:
Practice Address - Street 1:4309 3RD AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-1407
Practice Address - Country:US
Practice Address - Phone:619-876-4502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA216427164X00000X
CAVN216427164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse