Healthcare Provider Details

I. General information

NPI: 1811808157
Provider Name (Legal Business Name): MITRA HESHMATPOUR FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 GOSHEN AVE APT 107
LOS ANGELES CA
90049-6370
US

IV. Provider business mailing address

11800 GOSHEN AVE APT 107
LOS ANGELES CA
90049-6370
US

V. Phone/Fax

Practice location:
  • Phone: 310-945-7535
  • Fax:
Mailing address:
  • Phone: 310-945-7535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95039342
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: