MEDICARE: KRISTEN MICHELE PRUSA AGACNP-BC

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	363LA2100X	Acute Care Nurse Practitioner	95017466	CA
2	363L00000X	Nurse Practitioner	95017466	CA

General Provider Information

NPI Number	:	1477120582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN MICHELE PRUSA AGACNP-BC

Provider Business Mailing Address
First Line	:	16260 VENTURA BLVD STE LL15
Second Line	:
City	:	ENCINO
State	:	CA
Zip	:	91436-4931
Country	:	US
Telephone Number	:	818-905-1567
Fax Number	:	818-905-7406

Provider Business Practice Location Address
First Line	:	191 S BUENA VISTA ST STE 215
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-4563
Country	:	US
Telephone Number	:	818-906-4071
Fax Number	:	818-905-7406

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

Provider Enumeration Date	:	06/07/2021
Last Update Date	:	02/23/2022

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