Basic Information
| Provider Information | |||||||||
| NPI: | 1528715653 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHIBWETH | ||||||||
| FirstName: | DOREEN | ||||||||
| MiddleName: | DORA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2179 MANZANA WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921394018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1619316981 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3090 BRISTOL ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926263061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887899585 | ||||||||
| FaxNumber: | 5628034500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2022 | ||||||||
| LastUpdateDate: | 03/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95019707 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.