Healthcare Provider Details

I. General information

NPI: 1427094333
Provider Name (Legal Business Name): CAROL M VAZIRZADEH KAMJOU NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N STATE ST
LOS ANGELES CA
90033-1029
US

IV. Provider business mailing address

11356 NEBRASKA AVE
LOS ANGELES CA
90025-4222
US

V. Phone/Fax

Practice location:
  • Phone: 323-226-7556
  • Fax: 323-226-2657
Mailing address:
  • Phone: 310-966-1996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14049
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number14049
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: