Basic Information
| Provider Information | |||||||||
| NPI: | 1053759357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROSS | ||||||||
| FirstName: | RACHELLE | ||||||||
| MiddleName: | Q | ||||||||
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| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | QUIMPO | ||||||||
| OtherFirstName: | RACHELLE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 393 E WALNUT ST FL 3 | ||||||||
| Address2: | PHR GROUP PROVIDER ENROLLMENT UNIT | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911880001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776080044 | ||||||||
| FaxNumber: | 8775140903 | ||||||||
| Practice Location | |||||||||
| Address1: | 19353 VICTORY BLVD | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913356302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628663892 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2013 | ||||||||
| LastUpdateDate: | 02/16/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 22751 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.