MEDICARE: MARIAN NAKIJOBA SERUNJOGI FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	21882	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	500443	OTHER	CA	REGISTERED NURSE
2	76100	OTHER	CA	PUBLIC HEALTH NURSE
3	21882	OTHER	CA	FAMILY NURSE PRACTICTIONER

General Provider Information

NPI Number	:	1376898833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIAN NAKIJOBA SERUNJOGI FNP

Provider Business Mailing Address
First Line	:	27656 IRIS PL
Second Line	:
City	:	CASTAIC
State	:	CA
Zip	:	91384-3792
Country	:	US
Telephone Number	:	661-775-1832
Fax Number	:

Provider Business Practice Location Address
First Line	:	1911 W GLENOAKS BLVD STE B
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91201-4746
Country	:	US
Telephone Number	:	818-843-6640
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2012
Last Update Date	:	07/19/2012

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