Provider Demographics
NPI:1508254095
Name:TITTLE, TITIAN OGO (NP)
Entity Type:Individual
Prefix:
First Name:TITIAN
Middle Name:OGO
Last Name:TITTLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16653 SAN SIMEON WAY
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1453
Mailing Address - Country:US
Mailing Address - Phone:424-200-3639
Mailing Address - Fax:
Practice Address - Street 1:16653 SAN SIMEON WAY
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1453
Practice Address - Country:US
Practice Address - Phone:424-200-3639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-06
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001687363LF0000X
CANP95001687364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health