Provider Demographics
NPI:1417628173
Name:REQUENA, PRICILLA ADELIA
Entity Type:Individual
Prefix:
First Name:PRICILLA
Middle Name:ADELIA
Last Name:REQUENA
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 1:11118 S OSAGE AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90304-2967
Mailing Address - Country:US
Mailing Address - Phone:424-581-2844
Mailing Address - Fax:424-581-2844
Practice Address - Street 1:11118 S OSAGE AVE APT 7
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90304-2967
Practice Address - Country:US
Practice Address - Phone:424-581-2844
Practice Address - Fax:424-581-2844
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANON376K00000X
CA123765376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF1168310Medicaid