Provider Demographics
NPI:1619944949
Name:MOGHADAM, MARCI (NP)
Entity Type:Individual
Prefix:
First Name:MARCI
Middle Name:
Last Name:MOGHADAM
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 1:16729 ALGINET PL
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4119
Mailing Address - Country:US
Mailing Address - Phone:310-514-7999
Mailing Address - Fax:
Practice Address - Street 1:16720 ALGINET PLACE
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4119
Practice Address - Country:US
Practice Address - Phone:310-514-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-06
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15521363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily