=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346086089
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATRINA BAERA NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2024
-----------------------------------------------------
Last Update Date | 07/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3530 WILSHIRE BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90010-2328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-624-4824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1622 W 82ND ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90047-2868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-667-4803
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 95026922
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------