Basic Information
Provider Information
NPI: 1255569497
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ROMERO
FirstName: GRACE
MiddleName: KANG
NamePrefix:  
NameSuffix:  
Credential: N.P
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 26877 CHERRY WILLOW DR
Address2:  
City: SANTA CLARITA
State: CA
PostalCode: 913871813
CountryCode: US
TelephoneNumber: 5628797904
FaxNumber:  
Practice Location
Address1: 100 MEDICAL PLAZA #630
Address2:  
City: LOS ANGELES
State: CA
PostalCode: 900955310
CountryCode: US
TelephoneNumber: 3108259011
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/25/2009
LastUpdateDate: 03/17/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363L00000X17695CAY Physician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner 

No ID Information.


Home