Provider Demographics
NPI:1336541481
Name:LAGEOSE, BERTHA ALICIA (NP)
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:ALICIA
Last Name:LAGEOSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BERTHA
Other - Middle Name:ALICIA
Other - Last Name:ACOSTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:5533 SPANISH OAK LN UNIT E
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91377-3730
Mailing Address - Country:US
Mailing Address - Phone:818-991-9439
Mailing Address - Fax:
Practice Address - Street 1:757 WESTWOOD PLZ
Practice Address - Street 2:PEDIATRIC INTENSIVE CARE UNIT, RRUCLA
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-8358
Practice Address - Country:US
Practice Address - Phone:310-267-7540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9490363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care