MEDICARE: RHEA LARON CRISOSTOMO NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	95032263	CA

General Provider Information

NPI Number	:	1568298313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RHEA LARON CRISOSTOMO NP

Provider Business Mailing Address
First Line	:	1500 SAN PABLO ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90033-5313
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3210 W PICO BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90019-3643
Country	:	US
Telephone Number	:	323-734-2171
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2024
Last Update Date	:	06/11/2025

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