Healthcare Provider Details

I. General information

NPI: 1063675957
Provider Name (Legal Business Name): MARION ELEANOR MCRAE RN, NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 WESTWOOD PLZ
LOS ANGELES CA
90095-8358
US

IV. Provider business mailing address

118 SOUTH CLARK DRIVE #102
WEST HOLLYWOOD CA
90048
US

V. Phone/Fax

Practice location:
  • Phone: 310-267-7765
  • Fax:
Mailing address:
  • Phone: 310-994-1780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberNP15934
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN457714
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: