=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184920050
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICTORIA OMUSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2011
-----------------------------------------------------
Last Update Date | 10/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9808 VENICE BLVD SUITE 700
-----------------------------------------------------
City | CULVER CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90232-2732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-945-3350
-----------------------------------------------------
Fax | 310-840-7023
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4570
-----------------------------------------------------
City | PALOS VERDES PENINSULA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90274-9607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-400-7748
-----------------------------------------------------
Fax | 424-400-7749
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WP0809X
-----------------------------------------------------
Taxonomy Name | Adult Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | 494863
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 494863
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------