Provider Demographics
NPI:1528715653
Name:CHIBWETH, DOREEN DORA (NP)
Entity type:Individual
Prefix:
First Name:DOREEN
Middle Name:DORA
Last Name:CHIBWETH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2179 MANZANA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-4018
Mailing Address - Country:US
Mailing Address - Phone:161-931-6981
Mailing Address - Fax:
Practice Address - Street 1:3090 BRISTOL ST STE 200
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3061
Practice Address - Country:US
Practice Address - Phone:888-789-9585
Practice Address - Fax:562-803-4500
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95019707363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily