Healthcare Provider Details

I. General information

NPI: 1689293946
Provider Name (Legal Business Name): MICHELLE BASA LLERENAS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 WESTWOOD PLZ
LOS ANGELES CA
90095-8358
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-267-7565
  • Fax:
Mailing address:
  • Phone: 310-267-7565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number95022072
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number95022072
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number759587
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: