Healthcare Provider Details

I. General information

NPI: 1629596838
Provider Name (Legal Business Name): LIZETTE LYNN MATIONG RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 FIRWOOD
IRVINE CA
92604-4635
US

IV. Provider business mailing address

63 FIRWOOD
IRVINE CA
92604-4635
US

V. Phone/Fax

Practice location:
  • Phone: 714-357-9020
  • Fax: 949-214-3284
Mailing address:
  • Phone: 714-357-9020
  • Fax: 949-214-3284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number591509
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: