Healthcare Provider Details

I. General information

NPI: 1588078307
Provider Name (Legal Business Name): STACEY SKURA ZEDECK R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10833 LE CONTE AVE ROOM 12-430 MDCC
LOS ANGELES CA
90095-3075
US

IV. Provider business mailing address

10833 LE CONTE AVE ROOM 12-430 MDCC
LOS ANGELES CA
90095-3075
US

V. Phone/Fax

Practice location:
  • Phone: 310-794-5561
  • Fax: 310-825-9832
Mailing address:
  • Phone: 310-794-5561
  • Fax: 310-825-9832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number555064
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: