Provider Demographics
NPI:1467778696
Name:ITO, DIANNE MITSUKO (PNP)
Entity Type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:MITSUKO
Last Name:ITO
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3162
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-8162
Mailing Address - Country:US
Mailing Address - Phone:949-275-3265
Mailing Address - Fax:
Practice Address - Street 1:4650 SUNSET BOULEVARD
Practice Address - Street 2:MAILSTOP #81
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-0980
Practice Address - Country:US
Practice Address - Phone:323-361-3033
Practice Address - Fax:323-361-8191
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-13
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA457020363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics