Provider Demographics
NPI:1770100950
Name:CARRIGAN, DAPHNE MAE (LVN)
Entity type:Individual
Prefix:MRS
First Name:DAPHNE
Middle Name:MAE
Last Name:CARRIGAN
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 1:11614 ANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3457
Mailing Address - Country:US
Mailing Address - Phone:909-754-1128
Mailing Address - Fax:909-894-4700
Practice Address - Street 1:11614 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3457
Practice Address - Country:US
Practice Address - Phone:909-754-1128
Practice Address - Fax:909-894-4700
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-03
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA150838164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA150838Medicaid