Healthcare Provider Details

I. General information

NPI: 1710314323
Provider Name (Legal Business Name): ROSE MAE PAVINO CHUNG PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 12/18/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 SKYPARK DR STE 220
TORRANCE CA
90505-5035
US

IV. Provider business mailing address

3835 N FREEWAY BLVD STE 100
SACRAMENTO CA
95834-1954
US

V. Phone/Fax

Practice location:
  • Phone: 855-427-2778
  • Fax: 310-257-5753
Mailing address:
  • Phone: 916-576-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number791980
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95027772
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: