Provider Demographics
NPI:1104293067
Name:BUNGABONG, SILICA DIOCA
Entity type:Individual
Prefix:
First Name:SILICA
Middle Name:DIOCA
Last Name:BUNGABONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4619 ROSEWOOD AVE APT 106
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-1890
Mailing Address - Country:US
Mailing Address - Phone:323-557-6317
Mailing Address - Fax:
Practice Address - Street 1:4619 ROSEWOOD AVE APT 106
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-1890
Practice Address - Country:US
Practice Address - Phone:323-557-6317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95002654363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily