Healthcare Provider Details

I. General information

NPI: 1104598168
Provider Name (Legal Business Name): BRIANNE KATE O'DONOGHUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2021
Last Update Date: 09/29/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3837 S VERMONT AVE.
LOS ANGELES CA
90007
US

IV. Provider business mailing address

3031 S VERMONT AVE
LOS ANGELES CA
90007-3033
US

V. Phone/Fax

Practice location:
  • Phone: 323-766-2345
  • Fax:
Mailing address:
  • Phone: 323-373-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: