Healthcare Provider Details

I. General information

NPI: 1982740866
Provider Name (Legal Business Name): JANE AMBER COPILOW RNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 OCEAN PARK BLVD
SANTA MONICA CA
90405-4901
US

IV. Provider business mailing address

111 WAVECREST AVE
VENICE CA
90291-3369
US

V. Phone/Fax

Practice location:
  • Phone: 310-450-4773
  • Fax: 310-450-0873
Mailing address:
  • Phone: 310-392-3287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number377033
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: