Healthcare Provider Details

I. General information

NPI: 1619702016
Provider Name (Legal Business Name): ARDEN L VAN AMBURG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 09/05/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3491 CAHUENGA BLVD W UNIT A
LOS ANGELES CA
90068-1338
US

IV. Provider business mailing address

19847 SELENE CT
PORTER RANCH CA
91326-4301
US

V. Phone/Fax

Practice location:
  • Phone: 818-431-1118
  • Fax:
Mailing address:
  • Phone: 818-288-5970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-305255
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: