Healthcare Provider Details

I. General information

NPI: 1508317843
Provider Name (Legal Business Name): ANAITA JASMINE PANTHAKY MSN, AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

1821 CONTESSA
IRVINE CA
92620-1735
US

V. Phone/Fax

Practice location:
  • Phone: 877-558-8000
  • Fax:
Mailing address:
  • Phone: 714-206-6188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95005288
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number95005288
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: