Provider Demographics
NPI:1174234983
Name:FORTUNATO, MARIA DELIA DEJARME (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MARIA DELIA
Middle Name:DEJARME
Last Name:FORTUNATO
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 1:4211 AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-5622
Mailing Address - Country:US
Mailing Address - Phone:323-233-0425
Mailing Address - Fax:323-499-3619
Practice Address - Street 1:4211 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-5622
Practice Address - Country:US
Practice Address - Phone:323-233-0425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-13
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95023985363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner