Provider Demographics
NPI:1639574569
Name:VIZCARRA, KARINA
Entity Type:Individual
Prefix:
First Name:KARINA
Middle Name:
Last Name:VIZCARRA
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 1:13247 FOOTHILL BLVD
Mailing Address - Street 2:12202
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-9677
Mailing Address - Country:US
Mailing Address - Phone:909-559-1658
Mailing Address - Fax:
Practice Address - Street 1:1517 W GARVEY AVE N
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2138
Practice Address - Country:US
Practice Address - Phone:626-962-6061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37744167G00000X
CA167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician