Provider Demographics
NPI:1275146771
Name:LAVARREDA, CHARISE LAVONE (FNP)
Entity Type:Individual
Prefix:
First Name:CHARISE
Middle Name:LAVONE
Last Name:LAVARREDA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 N CHINA LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-3130
Mailing Address - Country:US
Mailing Address - Phone:760-446-3700
Mailing Address - Fax:760-446-3705
Practice Address - Street 1:900 N HERITAGE DR STE A
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-5540
Practice Address - Country:US
Practice Address - Phone:760-446-3700
Practice Address - Fax:760-446-3705
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95037582363LF0000X
CA95015768363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily