Healthcare Provider Details

I. General information

NPI: 1659557536
Provider Name (Legal Business Name): MISS FRIZETTE DODSON PUA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16260 VENTURA BLVD
ENCINO CA
91436-2203
US

IV. Provider business mailing address

12741 ROSEBROOK WAY
STANTON CA
90680-4013
US

V. Phone/Fax

Practice location:
  • Phone: 747-998-0387
  • Fax:
Mailing address:
  • Phone: 714-757-8871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95028989
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: