Provider Demographics
NPI:1912445990
Name:BUENO, LISSETTE
Entity Type:Individual
Prefix:
First Name:LISSETTE
Middle Name:
Last Name:BUENO
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 1:458 EVANWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-3619
Mailing Address - Country:US
Mailing Address - Phone:626-642-6887
Mailing Address - Fax:
Practice Address - Street 1:1517 WEST GARVEY AVE NORTH
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790
Practice Address - Country:US
Practice Address - Phone:626-962-6061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator