Healthcare Provider Details

I. General information

NPI: 1659306447
Provider Name (Legal Business Name): GRACE CHERRY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 06/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PLZ #365,214,420,120,510
LOS ANGELES CA
90095-3075
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 200
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-794-1092
  • Fax:
Mailing address:
  • Phone: 310-794-1092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number15069
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number424933
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number15069
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: