Provider Demographics
NPI:1619055696
Name:EDMUNDS, KATHLEEN SHANNON (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:SHANNON
Last Name:EDMUNDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2138 MALCOLM AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6306
Mailing Address - Country:US
Mailing Address - Phone:310-597-0736
Mailing Address - Fax:
Practice Address - Street 1:111 N SEPULVEDA BLVD
Practice Address - Street 2:STE. 210
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-6861
Practice Address - Country:US
Practice Address - Phone:310-379-2134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0177207P00000X
CAA101151207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine