Healthcare Provider Details

I. General information

NPI: 1023837671
Provider Name (Legal Business Name): NATALIE ROSE NISPEROS DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 12/30/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6041 CADILLAC AVE
LOS ANGELES CA
90034-1702
US

IV. Provider business mailing address

5717 LAUREL CANYON BLVD APT 105
VALLEY VILLAGE CA
91607-5202
US

V. Phone/Fax

Practice location:
  • Phone: 833-574-2273
  • Fax:
Mailing address:
  • Phone: 661-713-3692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: