Provider Demographics
NPI:1255002689
Name:DAVID, JELLIE D (RRT, RCP)
Entity Type:Individual
Prefix:
First Name:JELLIE
Middle Name:D
Last Name:DAVID
Suffix:
Gender:F
Credentials:RRT, RCP
Other - Prefix:
Other - First Name:JELLIE
Other - Middle Name:D
Other - Last Name:BUNTAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25825 VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-3518
Mailing Address - Country:US
Mailing Address - Phone:833-574-2273
Mailing Address - Fax:
Practice Address - Street 1:25825 VERMONT AVE
Practice Address - Street 2:
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-3518
Practice Address - Country:US
Practice Address - Phone:833-574-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35544227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered