Healthcare Provider Details

I. General information

NPI: 1174794358
Provider Name (Legal Business Name): EMILY PANICH RN, NP, CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 10/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11080 W OLYMPIC BLVD
LOS ANGELES CA
90064-1937
US

IV. Provider business mailing address

11080 W OLYMPIC BLVD
LOS ANGELES CA
90064-1937
US

V. Phone/Fax

Practice location:
  • Phone: 310-966-6521
  • Fax:
Mailing address:
  • Phone: 310-966-6515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number18456
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number3222
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number685498
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: