Provider Demographics
NPI:1023320140
Name:VERSAILLES, LUCILLE (LVN)
Entity type:Individual
Prefix:MS
First Name:LUCILLE
Middle Name:
Last Name:VERSAILLES
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2161 W. 25TH STREET
Mailing Address - Street 2:#34
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-4135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2161 W. 25TH STREET
Practice Address - Street 2:#34
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-4135
Practice Address - Country:US
Practice Address - Phone:310-547-1574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142526164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse