Provider Demographics
NPI:1609538040
Name:DIZON, REGINA BACANI (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:BACANI
Last Name:DIZON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 W WARNER AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92707-3147
Mailing Address - Country:US
Mailing Address - Phone:714-957-0611
Mailing Address - Fax:714-557-4339
Practice Address - Street 1:2231 E LENITA LN APT M
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-7958
Practice Address - Country:US
Practice Address - Phone:714-348-9145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018663363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health