Basic Information
| Provider Information | |||||||||
| NPI: | 1174601058 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VA GLAHS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21917 LOPEZ ST | ||||||||
| Address2: | |||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913643121 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11301 WILSHIRE BLVD | ||||||||
| Address2: | BLDG 500 ROOM 6208 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900731003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104783711 | ||||||||
| FaxNumber: | 3102684038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 3104783711 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | ND, ACRN, BC, FNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | 482522 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.