Provider Demographics
NPI:1720251820
Name:PETTINELLI, LISA JO (RRT, RN)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:JO
Last Name:PETTINELLI
Suffix:
Gender:F
Credentials:RRT, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6362 COLGATE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-4407
Mailing Address - Country:US
Mailing Address - Phone:310-717-9048
Mailing Address - Fax:
Practice Address - Street 1:3450 WILSHIRE BLVD
Practice Address - Street 2:SUITE 840
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2208
Practice Address - Country:US
Practice Address - Phone:310-717-9048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA591340163WH0200X
CA000111412279H0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No2279H0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredHome Health