Provider Demographics
NPI:1104170844
Name:REZAEI-HOMAMI, LALEH (PNP)
Entity type:Individual
Prefix:MS
First Name:LALEH
Middle Name:
Last Name:REZAEI-HOMAMI
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:LALEH
Other - Middle Name:
Other - Last Name:REZAEI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:650-652-8720
Mailing Address - Fax:
Practice Address - Street 1:901 CAMPUS DR STE 111
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-4930
Practice Address - Country:US
Practice Address - Phone:650-652-8720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-02
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002540363LP0200X
TX151187163W00000X
NYF382357-1363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse