Provider Demographics
NPI:1205498821
Name:MONAZZAM, ALICIA DANIELLE (NP)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:DANIELLE
Last Name:MONAZZAM
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 1:16215 WAYFARER LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-2149
Mailing Address - Country:US
Mailing Address - Phone:805-441-4057
Mailing Address - Fax:
Practice Address - Street 1:4067 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-6146
Practice Address - Country:US
Practice Address - Phone:323-569-1126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011373363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty