Provider Demographics
NPI:1700423266
Name:MONDOR, AMANDA LEE (NP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:MONDOR
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 1:6281 SANTA BARBARA AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92845-1246
Mailing Address - Country:US
Mailing Address - Phone:310-562-1399
Mailing Address - Fax:
Practice Address - Street 1:6281 SANTA BARBARA AVE
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92845-1246
Practice Address - Country:US
Practice Address - Phone:310-562-1399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012357363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care