Healthcare Provider Details

I. General information

NPI: 1700403409
Provider Name (Legal Business Name): LYDIA HARO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5562 PHILADELPHIA ST
CHINO CA
91710-2466
US

IV. Provider business mailing address

2952 MARKET ST
SAN DIEGO CA
92102-3241
US

V. Phone/Fax

Practice location:
  • Phone: 909-614-4412
  • Fax:
Mailing address:
  • Phone: 619-798-4613
  • Fax: 833-570-2124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95011947
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: