Healthcare Provider Details

I. General information

NPI: 1558807024
Provider Name (Legal Business Name): ALLAIN JULIAN CAMANAG VICTORIANO RN, PHN, AGPCNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 LAKEWOOD BLVD
DOWNEY CA
90240-4020
US

IV. Provider business mailing address

15723 THORNLAKE AVE
NORWALK CA
90650-6768
US

V. Phone/Fax

Practice location:
  • Phone: 562-862-3684
  • Fax:
Mailing address:
  • Phone: 562-275-5860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number95173882
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95026004
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: