Organization
GRACE OF ROSA LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KRYSTAL JANAE BLUNT LVN/LPN (CEO-NURSE)
(619) 874-3443
Entity
Organization
Contact information
Practice address
27317 MANZANITA LN APT 205, CANYON COUNTRY, CA 91387-5114
(619) 874-3443
Mailing address
27317 MANZANITA LN APT 205, CANYON COUNTRY, CA 91387-5114
(619) 874-3443
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
—
—
251B00000X
Case Management Agency
—
—
251E00000X
Home Health Agency
Primary
—
—
253Z00000X
In Home Supportive Care Agency
—
—
385H00000X
Respite Care
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
246816
ARIZONA STATE BOARD OF NURSING
AZ
01
—
718992
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS
CA
Enumeration date
08/19/2022
Last updated
08/19/2022
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