Provider Demographics
NPI:1871706226
Name:TETREAULT, DENISE DIANE (FNP)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:DIANE
Last Name:TETREAULT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5541 W 134TH PL
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-4913
Mailing Address - Country:US
Mailing Address - Phone:310-643-5620
Mailing Address - Fax:310-533-0447
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:BOX 449
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:310-222-2365
Practice Address - Fax:310-533-0447
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA319807363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily