Healthcare Provider Details

I. General information

NPI: 1780362541
Provider Name (Legal Business Name): LIZETTE EVENEZER OLMOS QUIJANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 W BADILLO ST
COVINA CA
91722-3762
US

IV. Provider business mailing address

530 W BADILLO ST
COVINA CA
91722-3762
US

V. Phone/Fax

Practice location:
  • Phone: 626-993-3000
  • Fax:
Mailing address:
  • Phone: 626-993-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: