Provider Demographics
NPI:1891533212
Name:BERNARDO, BENJAMIN BARLOW SRIVIRIYA (RN, PHN)
Entity type:Individual
Prefix:
First Name:BENJAMIN BARLOW
Middle Name:SRIVIRIYA
Last Name:BERNARDO
Suffix:
Gender:M
Credentials:RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 N SUNOL DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90063-1429
Mailing Address - Country:US
Mailing Address - Phone:323-362-1420
Mailing Address - Fax:
Practice Address - Street 1:133 N SUNOL DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90063-1429
Practice Address - Country:US
Practice Address - Phone:323-362-1420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95236859163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care