Provider Demographics
NPI:1083586077
Name:HIGGINBOTHAM, AMY (LVN)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:HIGGINBOTHAM
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 1:26000 W LUGONIA AVE APT 2422
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-5108
Mailing Address - Country:US
Mailing Address - Phone:951-692-6631
Mailing Address - Fax:951-686-6614
Practice Address - Street 1:2452 WILSHIRE ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-2144
Practice Address - Country:US
Practice Address - Phone:951-682-6631
Practice Address - Fax:951-686-6614
Is Sole Proprietor?:No
Enumeration Date:2025-09-19
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA257883164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse