Healthcare Provider Details

I. General information

NPI: 1164731485
Provider Name (Legal Business Name): LETICIA CAMANGEG ESTAVILLO NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2010
Last Update Date: 10/23/2021
Certification Date: 10/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23517 S. MAIN ST. #103
CARSON CA
90745-0000
US

IV. Provider business mailing address

23108 S VERMONT AVE
TORRANCE CA
90502-2933
US

V. Phone/Fax

Practice location:
  • Phone: 310-834-5388
  • Fax:
Mailing address:
  • Phone: 310-619-1851
  • Fax: 310-952-0681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP 20204
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: