Healthcare Provider Details

I. General information

NPI: 1770849416
Provider Name (Legal Business Name): KATHRYN SHANNON MCMENAMAN D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2012
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W LA VETA AVE
ORANGE CA
92868
US

IV. Provider business mailing address

2438 MANHATTAN AVE
HERMOSA BEACH CA
90254-2541
US

V. Phone/Fax

Practice location:
  • Phone: 323-333-0831
  • Fax:
Mailing address:
  • Phone: 323-333-0831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number20A-13050
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: