Provider Demographics
NPI:1750939096
Name:DE LARA, GRACE FERMINA (RN-BC, BSN)
Entity type:Individual
Prefix:
First Name:GRACE FERMINA
Middle Name:
Last Name:DE LARA
Suffix:
Gender:F
Credentials:RN-BC, BSN
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:DE LARA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN-BC, BSN
Mailing Address - Street 1:707 PANTERA DR
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1893
Mailing Address - Country:US
Mailing Address - Phone:909-800-6821
Mailing Address - Fax:
Practice Address - Street 1:11201 BENTON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92357-1000
Practice Address - Country:US
Practice Address - Phone:909-825-7084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA847841163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse