Provider Demographics
NPI:1306365523
Name:MASSOUA, FREDERIC
Entity Type:Individual
Prefix:
First Name:FREDERIC
Middle Name:
Last Name:MASSOUA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6417 CRENSHAW BLVD APT 15
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-3971
Mailing Address - Country:US
Mailing Address - Phone:424-221-0662
Mailing Address - Fax:
Practice Address - Street 1:6417 CRENSHAW BLVD APT 15
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-3971
Practice Address - Country:US
Practice Address - Phone:424-221-0662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALN281611164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse