Provider Demographics
NPI:1548779226
Name:REANTURCO, ELLYSE KATRINA
Entity Type:Individual
Prefix:
First Name:ELLYSE
Middle Name:KATRINA
Last Name:REANTURCO
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 1:1730 W OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-1019
Mailing Address - Country:US
Mailing Address - Phone:213-553-1884
Mailing Address - Fax:213-236-9662
Practice Address - Street 1:1730 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015
Practice Address - Country:US
Practice Address - Phone:213-553-1884
Practice Address - Fax:213-236-9662
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program