Healthcare Provider Details

I. General information

NPI: 1760112916
Provider Name (Legal Business Name): LORRAINE GAY DIZON LIWAG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2022
Last Update Date: 06/11/2022
Certification Date: 06/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 SCOTT RD APT H
BURBANK CA
91504-3875
US

IV. Provider business mailing address

1717 SCOTT RD APT H
BURBANK CA
91504-3875
US

V. Phone/Fax

Practice location:
  • Phone: 818-966-7260
  • Fax:
Mailing address:
  • Phone: 818-966-7260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95020655
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: