Provider Demographics
NPI:1336798586
Name:DOUGLAS, ERICA RENEE (LVN)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:RENEE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19635 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-6621
Mailing Address - Country:US
Mailing Address - Phone:213-435-2139
Mailing Address - Fax:
Practice Address - Street 1:1865 9TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-4501
Practice Address - Country:US
Practice Address - Phone:310-314-6200
Practice Address - Fax:310-450-2024
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA693140164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse