Provider Demographics
NPI:1417372426
Name:DIEGO, LEILANI FANG
Entity Type:Individual
Prefix:MRS
First Name:LEILANI
Middle Name:FANG
Last Name:DIEGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 PACIFIC COAST HWY STE S
Mailing Address - Street 2:
Mailing Address - City:LOMITA
Mailing Address - State:CA
Mailing Address - Zip Code:90717-2660
Mailing Address - Country:US
Mailing Address - Phone:562-787-1655
Mailing Address - Fax:
Practice Address - Street 1:1326 W CARSON ST APT 112
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-6500
Practice Address - Country:US
Practice Address - Phone:562-787-1655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-27
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23159363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily