Provider Demographics
NPI:1174284855
Name:GHOSH, LILLIAN MARY (NP)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:MARY
Last Name:GHOSH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 HAWK ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-2343
Mailing Address - Country:US
Mailing Address - Phone:818-825-4305
Mailing Address - Fax:
Practice Address - Street 1:13711 FOOTHILL BLVD UNIT B
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-3138
Practice Address - Country:US
Practice Address - Phone:818-408-8008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018094363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care