Healthcare Provider Details

I. General information

NPI: 1215816624
Provider Name (Legal Business Name): RANDY ATTYLA LUMBANTOBING DNP, PMHNP-BC, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2025
Last Update Date: 08/29/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST
LOMA LINDA CA
92350-1716
US

IV. Provider business mailing address

1764 N ENCINA AVE
RIALTO CA
92376-2938
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-4000
  • Fax:
Mailing address:
  • Phone: 909-566-9795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2025043688
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95227154
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: