Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0200X | Nurse Practitioner - Pediatrics | 95003631 | CA |
NPI | 1013373984 |
---|---|
Provider Name | Theresa Christina Disipio |
First Address | Los Angeles, CA 90027-6062 |
Second Address | Los Angeles, CA 90027-6062 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/01/2016 |
Last Update Date | 12/05/2016 |