Provider Demographics
NPI:1457646655
Name:FASANO, JORDAN (LVN)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:
Last Name:FASANO
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 1:31269 MANGROVE DR
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592
Mailing Address - Country:US
Mailing Address - Phone:858-337-4122
Mailing Address - Fax:
Practice Address - Street 1:31269 MANGROVE DR.
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592
Practice Address - Country:US
Practice Address - Phone:858-337-4122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA257921164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse