Provider Demographics
NPI:1720381650
Name:MANRIQUEZ, REGINA LEONOR
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:LEONOR
Last Name:MANRIQUEZ
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 1:12450 VAN NUYS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-1392
Mailing Address - Country:US
Mailing Address - Phone:626-395-7100
Mailing Address - Fax:
Practice Address - Street 1:12450 VAN NUYS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-1392
Practice Address - Country:US
Practice Address - Phone:626-395-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN226046164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse