Healthcare Provider Details

I. General information

NPI: 1568091619
Provider Name (Legal Business Name): MAYSA CHANCHUAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 04/01/2020
Certification Date: 04/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

1847 WINONA BLVD APT 307
LOS ANGELES CA
90027-3880
US

V. Phone/Fax

Practice location:
  • Phone: 310-478-3711
  • Fax:
Mailing address:
  • Phone: 818-405-8765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95013244
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number780355
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: