Provider Demographics
NPI:1417091083
Name:PROCTOR, MARY ELIZABETH (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:PROCTOR
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 1:7232 VAN NUYS BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-2231
Mailing Address - Country:US
Mailing Address - Phone:818-785-1890
Mailing Address - Fax:818-785-1922
Practice Address - Street 1:7232 VAN NUYS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2231
Practice Address - Country:US
Practice Address - Phone:818-785-1890
Practice Address - Fax:818-785-1922
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA451796363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology