Healthcare Provider Details

I. General information

NPI: 1902502909
Provider Name (Legal Business Name): FAVIOLA DON JUAN LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2023
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

852 W 19TH ST
SAN PEDRO CA
90731-5314
US

IV. Provider business mailing address

23608 PRESIDENT AVE
HARBOR CITY CA
90710-1007
US

V. Phone/Fax

Practice location:
  • Phone: 310-519-8723
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number689039
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: