Healthcare Provider Details

I. General information

NPI: 1467778696
Provider Name (Legal Business Name): DIANNE MITSUKO ITO PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2010
Last Update Date: 04/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 SUNSET BOULEVARD MAILSTOP #81
LOS ANGELES CA
90027-0980
US

IV. Provider business mailing address

PO BOX 3162
DANA POINT CA
92629-8162
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-3033
  • Fax: 323-361-8191
Mailing address:
  • Phone: 949-275-3265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number457020
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: