Provider Demographics
NPI:1114290178
Name:TEDJA-YEN, PINPIN PRISWALDY (NP)
Entity Type:Individual
Prefix:
First Name:PINPIN
Middle Name:PRISWALDY
Last Name:TEDJA-YEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22910 MOUNTAIN LAUREL WAY
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-2530
Mailing Address - Country:US
Mailing Address - Phone:909-895-9799
Mailing Address - Fax:
Practice Address - Street 1:420 S GLENDORA AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3001
Practice Address - Country:US
Practice Address - Phone:626-919-4333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-21
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA682814163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse