Healthcare Provider Details

I. General information

NPI: 1164629648
Provider Name (Legal Business Name): JESSICA GO-YANABU RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 N EDGEMONT ST BASEMENT, RM F 0023
LOS ANGELES CA
90027-5209
US

IV. Provider business mailing address

1505 N EDGEMONT ST BASEMENT, RM F 0023
LOS ANGELES CA
90027-5209
US

V. Phone/Fax

Practice location:
  • Phone: 323-783-5372
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number530677
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: