Provider Demographics
NPI:1699327593
Name:CASANOVA, RAQUEL (LICE TECHNICIAN)
Entity type:Individual
Prefix:MS
First Name:RAQUEL
Middle Name:
Last Name:CASANOVA
Suffix:
Gender:F
Credentials:LICE TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 E DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-6913
Mailing Address - Country:US
Mailing Address - Phone:209-290-8793
Mailing Address - Fax:
Practice Address - Street 1:1333 E DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-6913
Practice Address - Country:US
Practice Address - Phone:209-290-8793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20001341843747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant