Provider Demographics
NPI:1821313321
Name:PARADISE, KOLLEEN
Entity Type:Individual
Prefix:
First Name:KOLLEEN
Middle Name:
Last Name:PARADISE
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 1:43 1/2 THORNTON AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-3110
Mailing Address - Country:US
Mailing Address - Phone:619-405-2521
Mailing Address - Fax:
Practice Address - Street 1:835 E. CALAVERAS ST.
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001
Practice Address - Country:US
Practice Address - Phone:619-405-2521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60188819367500000X
CA3989367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered