1720011885 NPI number — DR. NANETTE DE FUENTES PH.D.

Table of content: DR. NANETTE DE FUENTES PH.D. (NPI 1720011885)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720011885 NPI number — DR. NANETTE DE FUENTES PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE FUENTES
Provider First Name:
NANETTE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720011885
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
138 N BRAND BLVD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91203-4614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-548-1122
Provider Business Mailing Address Fax Number:
323-254-4548

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
138 N BRAND BLVD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91203-4614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-548-1122
Provider Business Practice Location Address Fax Number:
323-254-4548
Provider Enumeration Date:
07/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY 11400 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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