Healthcare Provider Details

I. General information

NPI: 1942200571
Provider Name (Legal Business Name): DIANNE ROSE-DEYOUNG RNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 E 7TH ST ENT CLINIC 112
LONG BEACH CA
90822-5201
US

IV. Provider business mailing address

5901 E 7TH ST ENT CLINIC 112
LONG BEACH CA
90822-5201
US

V. Phone/Fax

Practice location:
  • Phone: 562-826-5558
  • Fax: 562-826-8119
Mailing address:
  • Phone: 562-826-5558
  • Fax: 562-826-8119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number249417
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: