Provider Demographics
NPI:1205660362
Name:MUNOZ KOTANKO, CONSTANZA (FNP-BC)
Entity type:Individual
Prefix:
First Name:CONSTANZA
Middle Name:
Last Name:MUNOZ KOTANKO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16630 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-2716
Mailing Address - Country:US
Mailing Address - Phone:310-768-8155
Mailing Address - Fax:
Practice Address - Street 1:16630 S BROADWAY
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-2716
Practice Address - Country:US
Practice Address - Phone:310-768-8155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95031035207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine