Provider Demographics
NPI:1508331737
Name:VISMANOS, LEAH (NP)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:VISMANOS
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 1:10440 EASTBORNE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-6175
Mailing Address - Country:US
Mailing Address - Phone:310-749-1850
Mailing Address - Fax:
Practice Address - Street 1:230 N MARYLAND AVE STE 110
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4283
Practice Address - Country:US
Practice Address - Phone:818-518-5980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009678363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner