Provider Demographics
NPI:1497642490
Name:BACA, JOURNEY BLUE (LVN)
Entity type:Individual
Prefix:
First Name:JOURNEY
Middle Name:BLUE
Last Name:BACA
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 1:850 N BENSON AVE # A82
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3551
Mailing Address - Country:US
Mailing Address - Phone:909-539-7038
Mailing Address - Fax:
Practice Address - Street 1:3686 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:JURUPA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92509-1948
Practice Address - Country:US
Practice Address - Phone:888-700-5053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA728922164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse