Healthcare Provider Details

I. General information

NPI: 1669014866
Provider Name (Legal Business Name): CHANNE BUNTHUNG FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2019
Last Update Date: 11/30/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 N PACIFIC COAST HWY
EL SEGUNDO CA
90245-4475
US

IV. Provider business mailing address

500 AVENUE G APT 3
REDONDO BEACH CA
90277-6006
US

V. Phone/Fax

Practice location:
  • Phone: 562-606-9165
  • Fax:
Mailing address:
  • Phone: 562-606-9165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95012449
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: