Healthcare Provider Details

I. General information

NPI: 1861978538
Provider Name (Legal Business Name): KATHLEEN ANN MCDONOUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2018
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11303 W WASHINGTON BLVD FL 2
LOS ANGELES CA
90066-6003
US

IV. Provider business mailing address

11303 W WASHINGTON BLVD FL 2
LOS ANGELES CA
90066-6003
US

V. Phone/Fax

Practice location:
  • Phone: 310-482-3260
  • Fax: 310-313-0768
Mailing address:
  • Phone: 310-482-3260
  • Fax: 310-313-0768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: