Healthcare Provider Details

I. General information

NPI: 1932933421
Provider Name (Legal Business Name): SOPHIA MARIE LUGO NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S BUENA VISTA ST
BURBANK CA
91505-4809
US

IV. Provider business mailing address

1267 STONER AVE APT 102
LOS ANGELES CA
90025-1679
US

V. Phone/Fax

Practice location:
  • Phone: 818-843-5111
  • Fax:
Mailing address:
  • Phone: 805-551-4994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95031078
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95031078
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: