Provider Demographics
NPI:1326813346
Name:CASEY, NISHENA MARIE
Entity Type:Individual
Prefix:
First Name:NISHENA
Middle Name:MARIE
Last Name:CASEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11374 MOUNTAIN VIEW AVE
Mailing Address - Street 2:DOVER BUILDING, SUITE A
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354
Mailing Address - Country:US
Mailing Address - Phone:909-558-4000
Mailing Address - Fax:
Practice Address - Street 1:11374 MOUNTAIN VIEW AVE
Practice Address - Street 2:DOVER BUILDING, SUITE B
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354
Practice Address - Country:US
Practice Address - Phone:909-558-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker