Provider Demographics
NPI:1831656578
Name:PANJAITAN, LUCYANA MAGRIETTA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:LUCYANA
Middle Name:MAGRIETTA
Last Name:PANJAITAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 BROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4090
Mailing Address - Country:US
Mailing Address - Phone:951-276-2760
Mailing Address - Fax:951-276-2960
Practice Address - Street 1:4500 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4090
Practice Address - Country:US
Practice Address - Phone:951-276-2760
Practice Address - Fax:951-276-2960
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-28
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95007651363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner