Healthcare Provider Details

I. General information

NPI: 1720251820
Provider Name (Legal Business Name): LISA JO PETTINELLI RRT, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 WILSHIRE BLVD SUITE 840
LOS ANGELES CA
90010-2208
US

IV. Provider business mailing address

6362 COLGATE AVE
LOS ANGELES CA
90048-4407
US

V. Phone/Fax

Practice location:
  • Phone: 310-717-9048
  • Fax:
Mailing address:
  • Phone: 310-717-9048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number591340
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2279H0200X
TaxonomyHome Health Registered Respiratory Therapist
License Number00011141
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: