Healthcare Provider Details

I. General information

NPI: 1245896604
Provider Name (Legal Business Name): GWENN PETRILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2019
Last Update Date: 05/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 ALCAZAR ST
LOS ANGELES CA
90089-0186
US

IV. Provider business mailing address

1540 ALCAZAR ST
LOS ANGELES CA
90089-0186
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: