Healthcare Provider Details

I. General information

NPI: 1891626982
Provider Name (Legal Business Name): AUDREY LYNN IBARRA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 N DIAMOND BAR BLVD STE B
DIAMOND BAR CA
91765-1059
US

IV. Provider business mailing address

933 WILLOW AVE
LA PUENTE CA
91746-1664
US

V. Phone/Fax

Practice location:
  • Phone: 909-396-8900
  • Fax:
Mailing address:
  • Phone: 562-325-7630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number6402
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: