Basic Information
| Provider Information | |||||||||
| NPI: | 1932646502 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FASSU SIANKAM | ||||||||
| FirstName: | LINE ORNELLA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4211 AVALON BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900115622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232330425 | ||||||||
| FaxNumber: | 3232322366 | ||||||||
| Practice Location | |||||||||
| Address1: | 2094 PITKIN AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112073509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182400400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2017 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P1300X | 76080 | CA | Y | Pharmacy Service Providers | Pharmacist | Psychiatric |
No ID Information.