Basic Information
| Provider Information | |||||||||
| NPI: | 1346673225 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HULTGREN | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | HULTGREN | ||||||||
| OtherFirstName: | DIANE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 975 FLYNN RD | ||||||||
| Address2: | |||||||||
| City: | CAMARILLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930128704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054467800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 975 FLYNN RD | ||||||||
| Address2: | |||||||||
| City: | CAMARILLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054457800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2013 | ||||||||
| LastUpdateDate: | 08/15/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.