Provider Demographics
NPI:1558911123
Name:LOMIBAO, GRACE M (MSN, RN, AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:M
Last Name:LOMIBAO
Suffix:
Gender:F
Credentials:MSN, RN, AGACNP-BC
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:M
Other - Last Name:MADRIGAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:8700 BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90048-1804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13517 BROWNING PL
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91746-1968
Practice Address - Country:US
Practice Address - Phone:951-258-8758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012594363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care