Provider Demographics
NPI:1942834296
Name:MATTAPPALLY, HARINA SHAJI
Entity Type:Individual
Prefix:
First Name:HARINA
Middle Name:SHAJI
Last Name:MATTAPPALLY
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 1:21339 BLACKHAWK ST
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-2311
Mailing Address - Country:US
Mailing Address - Phone:818-738-6155
Mailing Address - Fax:
Practice Address - Street 1:6850 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-4444
Practice Address - Country:US
Practice Address - Phone:818-782-4104
Practice Address - Fax:818-475-1823
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014015363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily