Healthcare Provider Details

I. General information

NPI: 1689897902
Provider Name (Legal Business Name): THEODORA GORE NURSE PRACTIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD # 53
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

1814 ARMOUR LANE
REDONDO BEACH CA
90278
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-7730
  • Fax:
Mailing address:
  • Phone: 310-379-2106
  • Fax: 310-680-9350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN522355
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN522355
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: