1760754659 NPI number — MRS. CARLYN MCLEAN FOSTAKOWSKY R.N., M.S.N., N.P.

Table of content: MRS. CARLYN MCLEAN FOSTAKOWSKY R.N., M.S.N., N.P. (NPI 1760754659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760754659 NPI number — MRS. CARLYN MCLEAN FOSTAKOWSKY R.N., M.S.N., N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOSTAKOWSKY
Provider First Name:
CARLYN
Provider Middle Name:
MCLEAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
R.N., M.S.N., N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCLEAN
Provider Other First Name:
CARLYN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
R.N., M.S.N., N.P.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760754659
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 SANTA MONICA BLVD
Provider Second Line Business Mailing Address:
SUITE 280W
Provider Business Mailing Address City Name:
SANTA MONICA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90404-2102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-829-7678
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 SANTA MONICA BLVD STE 280W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA MONICA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90404-2172
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-829-7678
Provider Business Practice Location Address Fax Number:
310-829-6889
Provider Enumeration Date:
02/07/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  21062 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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