Provider Demographics
NPI:1215493044
Name:DE LA ISLA BOLANOS, ANTONIA (LVN)
Entity type:Individual
Prefix:
First Name:ANTONIA
Middle Name:
Last Name:DE LA ISLA BOLANOS
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 1:5540 E LORENA AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-6330
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5540 E LORENA AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-6330
Practice Address - Country:US
Practice Address - Phone:559-916-3104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAWV203250164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse