Provider Demographics
NPI:1871030858
Name:PORCIUNCULA, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:PORCIUNCULA
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 1:7320 RESEDA BLVD
Mailing Address - Street 2:SUITE 371203
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91337-7001
Mailing Address - Country:US
Mailing Address - Phone:818-433-0262
Mailing Address - Fax:
Practice Address - Street 1:9301 WILSHIRE BLVD STE 404
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-6137
Practice Address - Country:US
Practice Address - Phone:310-278-9171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-27
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA804875163WG0000X
CA95005617363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice