Healthcare Provider Details

I. General information

NPI: 1831271196
Provider Name (Legal Business Name): COURTNEY DANE CARMICHAEL NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 12/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SANTA MONICA BLVD SUITE 1170 W
SANTA MONICA CA
90404-2102
US

IV. Provider business mailing address

16335 COMMUNITY ST
NORTH HILLS CA
91343-6211
US

V. Phone/Fax

Practice location:
  • Phone: 310-828-8399
  • Fax: 310-828-8331
Mailing address:
  • Phone: 818-282-6163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number16704
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: