Provider Demographics
NPI:1609538040
Name:DIZON, REGINA BACANI (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:BACANI
Last Name:DIZON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 SUPERIOR AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3641
Mailing Address - Country:US
Mailing Address - Phone:949-996-5355
Mailing Address - Fax:949-806-6901
Practice Address - Street 1:1501 SUPERIOR AVE STE 300
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3641
Practice Address - Country:US
Practice Address - Phone:949-996-5355
Practice Address - Fax:949-806-6901
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018663363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health