Healthcare Provider Details

I. General information

NPI: 1912743246
Provider Name (Legal Business Name): DEMITRIA KUPERSHMIDT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2024
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4312 WOODMAN AVE STE 102
SHERMAN OAKS CA
91423-5523
US

IV. Provider business mailing address

4816 DON PIO DR
WOODLAND HILLS CA
91364-4269
US

V. Phone/Fax

Practice location:
  • Phone: 818-770-8999
  • Fax:
Mailing address:
  • Phone: 818-770-8999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95030119
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: