Provider Demographics
NPI:1770280182
Name:PORTILLO, YESENIA (NP)
Entity type:Individual
Prefix:
First Name:YESENIA
Middle Name:
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4477 W 118TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-2257
Mailing Address - Country:US
Mailing Address - Phone:310-675-4440
Mailing Address - Fax:310-675-5816
Practice Address - Street 1:4477 W 118TH ST STE 200
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-2257
Practice Address - Country:US
Practice Address - Phone:310-675-4440
Practice Address - Fax:310-675-5816
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA95021315363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care