Basic Information
| Provider Information | |||||||||
| NPI: | 1558534685 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOGDANOV | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | DEL VILLAR | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 512185 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900510185 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 E. DUARTE ROAD | ||||||||
| Address2: | |||||||||
| City: | DUARTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262564673 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2008 | ||||||||
| LastUpdateDate: | 11/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP 17636 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | 17636 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | CNS 2814 | 01 | CA | CLINICAL NURSE SPECIALIST | OTHER | PHN 66386 | 01 | CA | PUBLIC HEALTHE NURSE | OTHER | NP 17636 | 01 | CA | NURSE PRACTITIONER LICENS | OTHER | RN 617845 | 01 | CA | REGISTERED NURSE LICENSE | OTHER |