Provider Demographics
NPI:1831860733
Name:KRUSE, JACQUELINE MCNALLY (RN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MCNALLY
Last Name:KRUSE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 S WINDSOR BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-4714
Mailing Address - Country:US
Mailing Address - Phone:323-788-7199
Mailing Address - Fax:
Practice Address - Street 1:434 S WINDSOR BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-4714
Practice Address - Country:US
Practice Address - Phone:323-788-7199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA585203163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse