Provider Demographics
NPI:1679878755
Name:YERENA, MONICA M
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:M
Last Name:YERENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-2436
Mailing Address - Country:US
Mailing Address - Phone:209-333-2711
Mailing Address - Fax:
Practice Address - Street 1:1601 LAKE ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-2436
Practice Address - Country:US
Practice Address - Phone:209-333-2711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 25447164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse