Provider Demographics
NPI:1851861983
Name:DERDZINSKA, PAULINE ANN (LVN)
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:ANN
Last Name:DERDZINSKA
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:PAULINE
Other - Middle Name:ANN
Other - Last Name:KUCZERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:1260 MORENA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3850
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1260 MORENA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3850
Practice Address - Country:US
Practice Address - Phone:619-275-0822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-02
Last Update Date:2018-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA276768164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician