Provider Demographics
NPI:1154926525
Name:CARDENAS, CRYSTAL (LVN)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:CARDENAS
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 1:100 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0510
Mailing Address - Country:US
Mailing Address - Phone:209-550-5860
Mailing Address - Fax:209-544-0487
Practice Address - Street 1:100 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0510
Practice Address - Country:US
Practice Address - Phone:209-550-5860
Practice Address - Fax:209-544-0487
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA714410164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty