Provider Demographics
NPI:1164731485
Name:ESTAVILLO, LETICIA CAMANGEG (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:CAMANGEG
Last Name:ESTAVILLO
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23108 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2933
Mailing Address - Country:US
Mailing Address - Phone:310-619-1851
Mailing Address - Fax:310-952-0681
Practice Address - Street 1:23517 S. MAIN ST. #103
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-0000
Practice Address - Country:US
Practice Address - Phone:310-834-5388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2021-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 20204363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner