Provider Demographics
NPI:1265191514
Name:SERRANO, DANA IVONNE (LMT, MMP)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:IVONNE
Last Name:SERRANO
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 KANSAS ST # 42
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4470
Mailing Address - Country:US
Mailing Address - Phone:909-698-8177
Mailing Address - Fax:
Practice Address - Street 1:1436 INDUSTRIAL PARK AVE # STUDIO17
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-4517
Practice Address - Country:US
Practice Address - Phone:909-698-8177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81655225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist