Provider Demographics
NPI:1336797125
Name:ANSELMO, FENDEE MADAYAG
Entity Type:Individual
Prefix:
First Name:FENDEE
Middle Name:MADAYAG
Last Name:ANSELMO
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 1:8097 CALENDULA DR
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-2005
Mailing Address - Country:US
Mailing Address - Phone:714-348-4783
Mailing Address - Fax:
Practice Address - Street 1:11845 W OLYMPIC BLVD STE 900W
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-5086
Practice Address - Country:US
Practice Address - Phone:213-296-3783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95142090163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice