Healthcare Provider Details

I. General information

NPI: 1790406882
Provider Name (Legal Business Name): PAVEL KSENDZ PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21700 GOLDEN TRIANGLE RD STE 104A
SANTA CLARITA CA
91350-2616
US

IV. Provider business mailing address

21700 GOLDEN TRIANGLE RD STE 104A
SANTA CLARITA CA
91350-2616
US

V. Phone/Fax

Practice location:
  • Phone: 310-849-4541
  • Fax:
Mailing address:
  • Phone: 310-849-4541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95021622
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: