Provider Demographics
NPI:1780259515
Name:RUSTANTO, RICHARD (MSN, RN)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:RUSTANTO
Suffix:
Gender:M
Credentials:MSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 SUNRISE WAY
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-7014
Mailing Address - Country:US
Mailing Address - Phone:818-585-3664
Mailing Address - Fax:
Practice Address - Street 1:1600 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-3932
Practice Address - Country:US
Practice Address - Phone:323-887-1313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95051858163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health