Provider Demographics
NPI:1851092415
Name:DE LEOZ, CHARLOTTEE
Entity Type:Individual
Prefix:
First Name:CHARLOTTEE
Middle Name:
Last Name:DE LEOZ
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 1:970 PARKSIDE ST
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-4242
Mailing Address - Country:US
Mailing Address - Phone:626-991-6729
Mailing Address - Fax:
Practice Address - Street 1:970 PARKSIDE ST
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-4242
Practice Address - Country:US
Practice Address - Phone:626-991-6729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95024455363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner