Healthcare Provider Details

I. General information

NPI: 1477120582
Provider Name (Legal Business Name): KRISTEN MICHELE PRUSA AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN MICHELE TANKURSLEY

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 S BUENA VISTA ST STE 215
BURBANK CA
91505-4563
US

IV. Provider business mailing address

16260 VENTURA BLVD STE LL15
ENCINO CA
91436-4931
US

V. Phone/Fax

Practice location:
  • Phone: 818-906-4071
  • Fax: 818-905-7406
Mailing address:
  • Phone: 818-905-1567
  • Fax: 818-905-7406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95017466
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95017466
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: