Provider Demographics
NPI:1598420143
Name:IMATONG, CHARISSE VINZELLE NACITO
Entity type:Individual
Prefix:
First Name:CHARISSE VINZELLE
Middle Name:NACITO
Last Name:IMATONG
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 1:8831 1/2 RAMONA ST
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-6334
Mailing Address - Country:US
Mailing Address - Phone:310-847-9227
Mailing Address - Fax:
Practice Address - Street 1:1209 HEMLOCK WAY
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92707-3609
Practice Address - Country:US
Practice Address - Phone:714-546-1966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA4402224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant