Healthcare Provider Details

I. General information

NPI: 1790304194
Provider Name (Legal Business Name): JENNIFER O TY-DE GUZMAN MSN, FNP,DNP,PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14023 PARAMOUNT BLVD
PARAMOUNT CA
90723-2605
US

IV. Provider business mailing address

14023 PARAMOUNT BLVD
PARAMOUNT CA
90723-2605
US

V. Phone/Fax

Practice location:
  • Phone: 562-988-3370
  • Fax: 562-988-3373
Mailing address:
  • Phone: 562-988-3370
  • Fax: 562-988-3373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number508898
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number12561
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: