Provider Demographics
NPI:1215816624
Name:LUMBANTOBING, RANDY ATTYLA (DNP, PMHNP-BC, RN)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:ATTYLA
Last Name:LUMBANTOBING
Suffix:
Gender:M
Credentials:DNP, PMHNP-BC, RN
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1764 N ENCINA AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-2938
Mailing Address - Country:US
Mailing Address - Phone:909-566-9795
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1716
Practice Address - Country:US
Practice Address - Phone:909-558-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-29
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95227154163W00000X
CA2025043688363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse