Provider Demographics
NPI:1194439919
Name:COMER, JUANDELLETTA
Entity type:Individual
Prefix:
First Name:JUANDELLETTA
Middle Name:
Last Name:COMER
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 1:1920 MARENGO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1317
Mailing Address - Country:US
Mailing Address - Phone:844-221-2276
Mailing Address - Fax:
Practice Address - Street 1:1920 MARENGO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1317
Practice Address - Country:US
Practice Address - Phone:844-221-2276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-06
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA193987163WP0808X, 164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health