Healthcare Provider Details

I. General information

NPI: 1891869806
Provider Name (Legal Business Name): MONICA SUSANNE DYBALSKI FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 W COLLEGE ST
LOS ANGELES CA
90012-1181
US

IV. Provider business mailing address

528 SANTA ANITA CT
SIERRA MADRE CA
91024-2623
US

V. Phone/Fax

Practice location:
  • Phone: 213-580-7344
  • Fax: 213-580-7307
Mailing address:
  • Phone: 626-355-0837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN363298, NP9439
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: