Healthcare Provider Details

I. General information

NPI: 1598420143
Provider Name (Legal Business Name): CHARISSE VINZELLE NACITO IMATONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 HEMLOCK WAY
SANTA ANA CA
92707-3609
US

IV. Provider business mailing address

8831 1/2 RAMONA ST
BELLFLOWER CA
90706-6334
US

V. Phone/Fax

Practice location:
  • Phone: 714-546-1966
  • Fax:
Mailing address:
  • Phone: 310-847-9227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA4402
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: