Provider Demographics
NPI:1316606817
Name:CRUZ, JILLIAN NIDEA (RN)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:NIDEA
Last Name:CRUZ
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2422 Q ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-6840
Mailing Address - Country:US
Mailing Address - Phone:916-606-8997
Mailing Address - Fax:
Practice Address - Street 1:2422 Q ST APT 2
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-6840
Practice Address - Country:US
Practice Address - Phone:916-606-8997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-12
Last Update Date:2021-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA801761163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse