Basic Information
Provider Information | |||||||||
NPI: | 1376502039 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SUPERVIZER | ||||||||
FirstName: | GITY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 23484 CALLE PEPITA RD | ||||||||
Address2: |   | ||||||||
City: | CORONA | ||||||||
State: | CA | ||||||||
PostalCode: | 928839353 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9512778067 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 23961 CALLE DE LA MAGDALENA | ||||||||
Address2: |   | ||||||||
City: | LAGUNA HILLS | ||||||||
State: | CA | ||||||||
PostalCode: | 926533665 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9495885800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2006 | ||||||||
LastUpdateDate: | 09/16/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 15664 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 173000000X | 15664 | CA | N |   | Other Service Providers | Legal Medicine |   |
No ID Information.