Healthcare Provider Details

I. General information

NPI: 1336800242
Provider Name (Legal Business Name): POLLY MUDITA DURSUM FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 01/03/2022
Certification Date: 01/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1722 STATE ST STE 101
SANTA BARBARA CA
93101-2526
US

IV. Provider business mailing address

540 CALLE ANZUELO
SANTA BARBARA CA
93111-1721
US

V. Phone/Fax

Practice location:
  • Phone: 805-969-9004
  • Fax:
Mailing address:
  • Phone: 818-404-9140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95017866
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: