Healthcare Provider Details

I. General information

NPI: 1487150744
Provider Name (Legal Business Name): AMELIA JEAN KOLENC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18226 VENTURA BLVD STE 102
TARZANA CA
91356-4246
US

IV. Provider business mailing address

6130 NEVADA AVE APT E215
WOODLAND HILLS CA
91367-3433
US

V. Phone/Fax

Practice location:
  • Phone: 818-905-5904
  • Fax:
Mailing address:
  • Phone: 412-508-0806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number950006669
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: