Healthcare Provider Details

I. General information

NPI: 1336797125
Provider Name (Legal Business Name): FENDEE MADAYAG ANSELMO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11845 W OLYMPIC BLVD STE 900W
LOS ANGELES CA
90064-5086
US

IV. Provider business mailing address

8097 CALENDULA DR
BUENA PARK CA
90620-2005
US

V. Phone/Fax

Practice location:
  • Phone: 213-296-3783
  • Fax:
Mailing address:
  • Phone: 714-348-4783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number95142090
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: