Healthcare Provider Details

I. General information

NPI: 1427525781
Provider Name (Legal Business Name): MISS LAUREN QIEU FENNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 10/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1865 9TH STREET
SANTA MONICA CA
90404
US

IV. Provider business mailing address

1865 9TH STREET
SANTA MONICA CA
90404
US

V. Phone/Fax

Practice location:
  • Phone: 310-314-6200
  • Fax: 310-450-2024
Mailing address:
  • Phone: 310-314-6200
  • Fax: 310-450-2024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: