Provider Demographics
NPI:1629445226
Name:CENTENO, RAFAEL (FNP)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:CENTENO
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 W WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4735
Mailing Address - Country:US
Mailing Address - Phone:323-712-4811
Mailing Address - Fax:
Practice Address - Street 1:833 W WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4735
Practice Address - Country:US
Practice Address - Phone:323-712-4811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CA95026957363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty