Provider Demographics
NPI:1215393384
Name:MUTUC, DESIRAE (FNP-C)
Entity Type:Individual
Prefix:
First Name:DESIRAE
Middle Name:
Last Name:MUTUC
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4955 VAN NUYS BLVD STE 308
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1811
Mailing Address - Country:US
Mailing Address - Phone:818-528-1044
Mailing Address - Fax:818-528-1261
Practice Address - Street 1:4955 VAN NUYS BLVD STE 308
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1811
Practice Address - Country:US
Practice Address - Phone:818-528-1044
Practice Address - Fax:818-528-1261
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003625363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily