Healthcare Provider Details

I. General information

NPI: 1548853872
Provider Name (Legal Business Name): CZARINA MARIE SANTOS VILLANUEVA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 08/14/2021
Certification Date: 08/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 EASTLAKE AVE
LOS ANGELES CA
90089-1019
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 323-865-3000
  • Fax:
Mailing address:
  • Phone: 323-865-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95016522
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: