Provider Demographics
NPI:1902554116
Name:CANONIZADO, JESSICA (LPN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CANONIZADO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4821 YEW LN SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3848
Mailing Address - Country:US
Mailing Address - Phone:253-232-5154
Mailing Address - Fax:
Practice Address - Street 1:2150 FREEMAN RD E
Practice Address - Street 2:
Practice Address - City:FIFE
Practice Address - State:WA
Practice Address - Zip Code:98424-3776
Practice Address - Country:US
Practice Address - Phone:253-942-5644
Practice Address - Fax:253-922-4722
Is Sole Proprietor?:No
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP61095545164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse