Basic Information
Provider Information | |||||||||
NPI: | 1679024731 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUTTON | ||||||||
FirstName: | JOSSETTE | ||||||||
MiddleName: | PORTILLO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | POSADAS | ||||||||
OtherFirstName: | JOSSETTE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 625 FAIR OAKS AVE STE 270 | ||||||||
Address2: |   | ||||||||
City: | SOUTH PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 910305801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6263462455 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5549 VAN BUREN BLVD | ||||||||
Address2: |   | ||||||||
City: | RIVERSIDE | ||||||||
State: | CA | ||||||||
PostalCode: | 925032068 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9513245901 | ||||||||
FaxNumber: | 8777789472 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2016 | ||||||||
LastUpdateDate: | 05/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95005189 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.