Provider Demographics
NPI:1760754659
Name:FOSTAKOWSKY, CARLYN MCLEAN (RN, MSN, NP)
Entity Type:Individual
Prefix:MRS
First Name:CARLYN
Middle Name:MCLEAN
Last Name:FOSTAKOWSKY
Suffix:
Gender:F
Credentials:RN, MSN, NP
Other - Prefix:
Other - First Name:CARLYN
Other - Middle Name:
Other - Last Name:MCLEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, MSN, NP
Mailing Address - Street 1:2001 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 280W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2102
Mailing Address - Country:US
Mailing Address - Phone:310-829-7678
Mailing Address - Fax:
Practice Address - Street 1:2001 SANTA MONICA BLVD STE 280W
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2172
Practice Address - Country:US
Practice Address - Phone:310-829-7678
Practice Address - Fax:310-829-6889
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21062363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care