Healthcare Provider Details

I. General information

NPI: 1184580029
Provider Name (Legal Business Name): JONATHAN KUSMULYANA NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2026
Last Update Date: 01/03/2026
Certification Date: 01/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26120 PLUMCOT DR
CORONA CA
92883-3141
US

IV. Provider business mailing address

26120 PLUMCOT DR
CORONA CA
92883-3141
US

V. Phone/Fax

Practice location:
  • Phone: 626-641-5054
  • Fax:
Mailing address:
  • Phone: 626-641-5054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP95037773
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: