Provider Demographics
NPI:1578186896
Name:MICA, CAMILLE AUBREY
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:AUBREY
Last Name:MICA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6363 WILSHIRE BLVD STE 520
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5727
Mailing Address - Country:US
Mailing Address - Phone:424-259-3238
Mailing Address - Fax:
Practice Address - Street 1:6363 WILSHIRE BLVD STE 520
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5727
Practice Address - Country:US
Practice Address - Phone:424-259-3238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program