Healthcare Provider Details

I. General information

NPI: 1215749296
Provider Name (Legal Business Name): MS. MICHELLE LYNN TAMAYO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2025
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8635 W 3RD ST STE 355
LOS ANGELES CA
90048-6112
US

IV. Provider business mailing address

4006 VAN BUREN PL
CULVER CITY CA
90232-2828
US

V. Phone/Fax

Practice location:
  • Phone: 323-655-7610
  • Fax:
Mailing address:
  • Phone: 520-461-9399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95030480
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: