=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508745233
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIN DEMARS BAGNALL
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2025
-----------------------------------------------------
Last Update Date | 10/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1534 N. MOORPARK RD. PO BOX #256 PO BOX 256
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91360-5129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-625-2257
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1534 N. MOORPARK RD. PO BOX #256 PO BOX 256
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91360-5129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-625-2257
-----------------------------------------------------
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 | 95037402
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------