Healthcare Provider Details

I. General information

NPI: 1205954989
Provider Name (Legal Business Name): FANNY DIEPPA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12099 W WASHINGTON BLVD STE 200
LOS ANGELES CA
90066-2622
US

IV. Provider business mailing address

12099 W WASHINGTON BLVD STE 200
LOS ANGELES CA
90066-2622
US

V. Phone/Fax

Practice location:
  • Phone: 301-751-1173
  • Fax:
Mailing address:
  • Phone: 301-751-1173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberDATA ENTRY
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: