Provider Demographics
NPI:1902013394
Name:MAGDALENO, NANCY A
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:A
Last Name:MAGDALENO
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 1:1442 N HILL AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-2614
Mailing Address - Country:US
Mailing Address - Phone:626-797-0246
Mailing Address - Fax:
Practice Address - Street 1:1020 S ARROYO PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3911
Practice Address - Country:US
Practice Address - Phone:626-403-2794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN220296164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAVN220296Medicaid