Healthcare Provider Details

I. General information

NPI: 1114528981
Provider Name (Legal Business Name): LORNA REGINA SANTIAGO SURATOS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 05/09/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD # 82
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

302 N MADISON AVE
MONROVIA CA
91016-1516
US

V. Phone/Fax

Practice location:
  • Phone: 307-259-2173
  • Fax:
Mailing address:
  • Phone: 307-259-2173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95018578
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95038191
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: