Healthcare Provider Details

I. General information

NPI: 1629754445
Provider Name (Legal Business Name): DEANELLE AMBER FIMBRES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 W REDONDO BEACH BLVD
GARDENA CA
90247-4128
US

IV. Provider business mailing address

7227 RICHFIELD ST APT 34
PARAMOUNT CA
90723-5739
US

V. Phone/Fax

Practice location:
  • Phone: 310-553-2695
  • Fax:
Mailing address:
  • Phone: 818-389-2317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number6314
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: