Provider Demographics
NPI:1588228738
Name:LY, JEANNET D (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JEANNET
Middle Name:D
Last Name:LY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:JEANNET
Other - Middle Name:D
Other - Last Name:LY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:2100 E ANAHEIM ST STE B
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-3419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 E ANAHEIM ST STE B
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-3419
Practice Address - Country:US
Practice Address - Phone:562-478-4102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011419363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily