Provider Demographics
NPI:1295492155
Name:PROMUTICO, MARY FRANCES
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:FRANCES
Last Name:PROMUTICO
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 1:1245 BIG CANYON PL
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3223
Mailing Address - Country:US
Mailing Address - Phone:424-342-3515
Mailing Address - Fax:
Practice Address - Street 1:23700 CAMINO DEL SOL
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5017
Practice Address - Country:US
Practice Address - Phone:310-784-2248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-25
Last Update Date:2021-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA347467163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health