Healthcare Provider Details

I. General information

NPI: 1780216911
Provider Name (Legal Business Name): JESSICA NARIO LUONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

1492 MONTGOMERY ST
TUSTIN CA
92782-1792
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-6800
  • Fax:
Mailing address:
  • Phone: 951-275-1395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number23425
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: