Basic Information
| Provider Information | |||||||||
| NPI: | 1013675073 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BIRDSALL | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | PAIGE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1722 ROGERS PL UNIT 25E | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915043668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079285206 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18300 ROSCOE BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913254105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188858500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2021 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 95018773 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 95018773 | 01 | CA | NURSE PRACTITIONER LICENSE NUMBER | OTHER | MB6917198 | 01 | DEA NUMBER | OTHER |