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Provider Information for 1053303883

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: FEMALE

Individual NPI: 1053303883

Calendar   Last Updated:  2007-07-08
  Certification Date: 


Name Value
NPI 1053303883
Enumeration Date 2005-08-18
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 1172 N MACLAY AVE
SAN FERNANDO, CA 91340-1328
United States

Phone: 818-898-1388 | Fax: 818-365-4031
View Map External Link
Primary Practice Address 1600 SAN FERNANDO RD
SAN FERNANDO, CA 91340-3115
United States

Phone: 818-365-8086 | Fax: 818-898-4826
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 208000000X - Pediatrics CA A78549