Provider Demographics
NPI:1255894408
Name:DAGHER, IDA
Entity type:Individual
Prefix:MRS
First Name:IDA
Middle Name:
Last Name:DAGHER
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 1:1814 JEANNA PL
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-9262
Mailing Address - Country:US
Mailing Address - Phone:626-833-6987
Mailing Address - Fax:
Practice Address - Street 1:35325 DATE PALM DR STE 107
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-7032
Practice Address - Country:US
Practice Address - Phone:760-202-4308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL9605374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374700000XNursing Service Related ProvidersTechnicianGroup - Single Specialty