Healthcare Provider Details

I. General information

NPI: 1598451445
Provider Name (Legal Business Name): JUSTENE ANN ILOG PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 W VISTA WAY STE 103
VISTA CA
92083-5735
US

IV. Provider business mailing address

3927 MESA DR APT 105
OCEANSIDE CA
92056-2624
US

V. Phone/Fax

Practice location:
  • Phone: 760-295-8727
  • Fax:
Mailing address:
  • Phone: 951-768-0182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95025318
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95219111
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: