Provider Demographics
NPI:1659395507
Name:PALMER, DEBORAH
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:PALMER
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 1:2060 HUNTINGTON DR STE 5
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-2044
Mailing Address - Country:US
Mailing Address - Phone:626-570-1993
Mailing Address - Fax:626-570-4993
Practice Address - Street 1:2060 HUNTINGTON DR STE 5
Practice Address - Street 2:
Practice Address - City:SAN MARINO
Practice Address - State:CA
Practice Address - Zip Code:91108-2044
Practice Address - Country:US
Practice Address - Phone:626-570-1993
Practice Address - Fax:626-570-4993
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABL 001681171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME02525FMedicaid
CADME02525FMedicaid