MEDICARE: BRIANNE KATE O'DONOGHUE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1104598168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIANNE KATE O'DONOGHUE

Provider Business Mailing Address
First Line	:	3031 S VERMONT AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90007-3033
Country	:	US
Telephone Number	:	323-373-2400
Fax Number	:

Provider Business Practice Location Address
First Line	:	3837 S VERMONT AVE.
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90007
Country	:	US
Telephone Number	:	323-766-2345
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2021
Last Update Date	:	09/29/2021

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