Provider Demographics
NPI:1881156032
Name:KOBYLKA, SHANNON NICOLE JANET (L AC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE JANET
Last Name:KOBYLKA
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9111 SUMMERTIME LN
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-4559
Mailing Address - Country:US
Mailing Address - Phone:323-363-4333
Mailing Address - Fax:
Practice Address - Street 1:10921 WILSHIRE BLVD STE 409
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4001
Practice Address - Country:US
Practice Address - Phone:323-363-4333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-04
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18491171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty