Healthcare Provider Details

I. General information

NPI: 1871706226
Provider Name (Legal Business Name): DENISE DIANE TETREAULT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W CARSON ST BOX 449
TORRANCE CA
90502-2004
US

IV. Provider business mailing address

5541 W 134TH PL
HAWTHORNE CA
90250-4913
US

V. Phone/Fax

Practice location:
  • Phone: 310-222-2365
  • Fax: 310-533-0447
Mailing address:
  • Phone: 310-643-5620
  • Fax: 310-533-0447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number319807
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: