Healthcare Provider Details

I. General information

NPI: 1326209883
Provider Name (Legal Business Name): MICHELLE ANN BOHLEN GNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD BLDG 5000 RM 4080
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

17224 MIDWOOD DR
GRANADA HILLS CA
91344-2452
US

V. Phone/Fax

Practice location:
  • Phone: 818-335-1114
  • Fax:
Mailing address:
  • Phone: 818-335-1114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number17543
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: