Healthcare Provider Details

I. General information

NPI: 1083473177
Provider Name (Legal Business Name): JEONGRAN CHAE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4221 WILSHIRE BLVD STE 170-14
LOS ANGELES CA
90010-3519
US

IV. Provider business mailing address

2700 E CHAUCER ST UNIT 6
LOS ANGELES CA
90065-1845
US

V. Phone/Fax

Practice location:
  • Phone: 323-272-3648
  • Fax:
Mailing address:
  • Phone: 818-744-0074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF07230300
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: