Healthcare Provider Details

I. General information

NPI: 1568638302
Provider Name (Legal Business Name): MRS. NATALIA USMANOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18044 VALLEY VISTA BLVD
ENCINO CA
91316-4223
US

IV. Provider business mailing address

18044 VALLEY VISTA BLVD
ENCINO CA
91316-4223
US

V. Phone/Fax

Practice location:
  • Phone: 818-943-8454
  • Fax: 619-393-0830
Mailing address:
  • Phone: 818-943-8454
  • Fax: 619-393-0830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number13099
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: