Healthcare Provider Details

I. General information

NPI: 1760339212
Provider Name (Legal Business Name): CHANELLE JALI CARDONA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2026
Last Update Date: 03/13/2026
Certification Date: 02/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5056 WHITSETT AVE APT 3
VALLEY VILLAGE CA
91607-3042
US

IV. Provider business mailing address

5056 WHITSETT AVE APT 3
VALLEY VILLAGE CA
91607-3042
US

V. Phone/Fax

Practice location:
  • Phone: 310-994-6380
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95038994
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: