Individual
JUSTENE ANN ILOG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PMHNP
Contact information
Practice address
550 W VISTA WAY STE 103, VISTA, CA 92083-5735
(760) 295-8727
Mailing address
3927 MESA DR APT 105, OCEANSIDE, CA 92056-2624
(951) 768-0182
Taxonomy
Speciality
Code
Description
License number
State
163WP0808X
Psychiatric/Mental Health Registered Nurse
95219111
CA
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
95025318
CA
Other
Enumeration date
04/13/2023
Last updated
08/22/2023
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