Healthcare Provider Details

I. General information

NPI: 1235819921
Provider Name (Legal Business Name): LISSIE JEANNINE VIGIL ROMERO NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 07/19/2023
Certification Date: 01/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 W 3RD ST STE 220
LOS ANGELES CA
90057-1993
US

IV. Provider business mailing address

ALTAMED HEALTH SERVICES CORP 2040 CAMFIELD AVE.
COMMERCE CA
90040
US

V. Phone/Fax

Practice location:
  • Phone: 323-765-6660
  • Fax:
Mailing address:
  • Phone: 323-765-6660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95022988
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: