Provider Demographics
NPI:1992348239
Name:BEREDO, LEONORA
Entity type:Individual
Prefix:
First Name:LEONORA
Middle Name:
Last Name:BEREDO
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 1:5650 JILLSON ST
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90040-1482
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:522 S SAN PEDRO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-2102
Practice Address - Country:US
Practice Address - Phone:562-867-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11004541363LF0000X
CA95013642363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily