Basic Information
| Provider Information | |||||||||
| NPI: | 1750939096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE LARA | ||||||||
| FirstName: | GRACE FERMINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN-BC, BSN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DE LARA | ||||||||
| OtherFirstName: | GRACE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | RN-BC, BSN | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 707 PANTERA DR | ||||||||
| Address2: | |||||||||
| City: | DIAMOND BAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917651893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098006821 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11201 BENTON ST | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923571000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098257084 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2019 | ||||||||
| LastUpdateDate: | 08/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 847841 | CA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.