Healthcare Provider Details

I. General information

NPI: 1639095243
Provider Name (Legal Business Name): SOFIA IACONO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12923 INGLEWOOD AVE
HAWTHORNE CA
90250-5573
US

IV. Provider business mailing address

17575 YUKON AVE
TORRANCE CA
90504-3448
US

V. Phone/Fax

Practice location:
  • Phone: 310-675-0395
  • Fax:
Mailing address:
  • Phone: 626-824-5396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95037585
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: