MEDICARE: MS. YICHUN MICHELLE FANG RN

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	163WG0000X	General Practice Registered Nurse	680110	CA
2	163WG0000X	General Practice Registered Nurse	18462	CA

General Provider Information

NPI Number	:	1225274624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. YICHUN MICHELLE FANG RN

Provider Business Mailing Address
First Line	:	2716 OCEAN PARK BLVD
Second Line	:	SUITE 3082
City	:	SANTA MONICA
State	:	CA
Zip	:	90405-5207
Country	:	US
Telephone Number	:	310-345-3818
Fax Number	:	310-314-2414

Provider Business Practice Location Address
First Line	:	2716 OCEAN PARK BLVD
Second Line	:	SUITE 3082
City	:	SANTA MONICA
State	:	CA
Zip	:	90405-5207
Country	:	US
Telephone Number	:	310-345-3818
Fax Number	:	310-314-2414

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

Provider Enumeration Date	:	01/06/2009
Last Update Date	:	01/07/2009

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