Provider Demographics
NPI:1316620222
Name:SETIOMIGUNO, CLARISSA LAURA
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:LAURA
Last Name:SETIOMIGUNO
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 1:18420 LEMARSH ST UNIT 26
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-1063
Mailing Address - Country:US
Mailing Address - Phone:818-398-5425
Mailing Address - Fax:
Practice Address - Street 1:14515 HAMLIN ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-1686
Practice Address - Country:US
Practice Address - Phone:818-989-7475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program