Provider Demographics
NPI:1598210403
Name:KO, DYANA (NP)
Entity Type:Individual
Prefix:
First Name:DYANA
Middle Name:
Last Name:KO
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 1:2615 PACIFIC COAST HWY STE 204
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-2227
Mailing Address - Country:US
Mailing Address - Phone:424-728-5564
Mailing Address - Fax:424-377-6548
Practice Address - Street 1:1000 N SEPULVEDA BLVD STE 280
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-5975
Practice Address - Country:US
Practice Address - Phone:424-229-2432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-20
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027496363LP0808X
CAL-132766163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant