Provider Demographics
NPI:1417400912
Name:CARRASCO, RENEE NICOLE (LVN)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:NICOLE
Last Name:CARRASCO
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 1:777 E SANTA CLARA ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-1934
Mailing Address - Country:US
Mailing Address - Phone:408-977-4504
Mailing Address - Fax:
Practice Address - Street 1:777 E SANTA CLARA ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-1934
Practice Address - Country:US
Practice Address - Phone:408-977-4504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-01
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 265731164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse