Provider Demographics
NPI:1831271196
Name:CARMICHAEL, COURTNEY DANE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:DANE
Last Name:CARMICHAEL
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16335 COMMUNITY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-6211
Mailing Address - Country:US
Mailing Address - Phone:818-282-6163
Mailing Address - Fax:
Practice Address - Street 1:2001 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 1170 W
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2102
Practice Address - Country:US
Practice Address - Phone:310-828-8399
Practice Address - Fax:310-828-8331
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16704363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ74038Medicare UPIN