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General NPI Number Information
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NPI Number | 1134641087
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Entity Type | Individual
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Provider Name | KELLY MICHELE MANDA FNP
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Gender | Female
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Dates
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Enumeration Date | 07/12/2017
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Last Update Date | 07/12/2017
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Provider Practice Location Address
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Address Line | 5363 BALBOA BLVD STE 245
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City | ENCINO
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State | CA
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Zip | 91316-2827
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Country | US
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Telephone | 818-343-4430
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Fax | 818-343-4423
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Provider Business Mailing Address
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Address Line | 3580 BUFFUM ST
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City | SIMI VALLEY
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State | CA
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Zip | 93063-3216
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Country | US
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Telephone | 818-585-5428
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Fax | 805-527-2603
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 95006929
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License Number State | CA
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