Provider Demographics
NPI:1952436651
Name:TRUBY, REVONIA J (NP)
Entity Type:Individual
Prefix:MS
First Name:REVONIA
Middle Name:J
Last Name:TRUBY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4203 LEVELSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712
Mailing Address - Country:US
Mailing Address - Phone:562-421-4375
Mailing Address - Fax:323-566-6896
Practice Address - Street 1:11905 SO CENTRAL AVE
Practice Address - Street 2:#201
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059
Practice Address - Country:US
Practice Address - Phone:323-566-6911
Practice Address - Fax:323-566-6896
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 1160363L00000X
CA202745364SW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Not Answered364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP0011600Medicaid