Basic Information
| Provider Information | |||||||||
| NPI: | 1780767269 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRELL | ||||||||
| FirstName: | PRISCILLA | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 512185 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900510185 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 DUARTE RD | ||||||||
| Address2: | |||||||||
| City: | DUARTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910103012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262564673 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X | 56516 | MA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207LP2900X | 56516 | MA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | G176678 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 5825897001 | 01 | MA | CIGNA | OTHER | 2205188 | 01 | MA | AETNA | OTHER | 0007050 | 01 | MA | NHP | OTHER | 3065472 | 05 | MA | MEDICAID | J10183 | 01 | MA | BCBS MA | OTHER | 056516 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 996622 | 01 | MA | NETWORK HEALTH | OTHER |