Provider Demographics
NPI:1053636720
Name:TATLONGHARI, ROY VILLENA (RN-CANP)
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:VILLENA
Last Name:TATLONGHARI
Suffix:
Gender:M
Credentials:RN-CANP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:P.O. BOX 27980, CHILDRENS HOSPITAL LOS ANGELES
Mailing Address - Street 2:MS 125
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-0980
Mailing Address - Country:US
Mailing Address - Phone:323-361-4206
Mailing Address - Fax:323-361-8095
Practice Address - Street 1:4650 SUNSET BLVD
Practice Address - Street 2:MS 125
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027
Practice Address - Country:US
Practice Address - Phone:323-361-2533
Practice Address - Fax:323-361-8095
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CALIC#604372363LA2200X, 363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA15203OtherFURNISHING LICENSE