Provider Demographics
NPI:1629575477
Name:PEGADO, LUIZA MIRANDA (LPN)
Entity Type:Individual
Prefix:
First Name:LUIZA
Middle Name:MIRANDA
Last Name:PEGADO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9040 JACKSON AVE ATTN: MCHJ-CLQ-C
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-1100
Mailing Address - Country:US
Mailing Address - Phone:253-968-3869
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE ATTN: MCHJ-CLQ-C
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-3869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX341944164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse