Basic Information
| Provider Information | |||||||||
| NPI: | 1043677289 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STOVALL | ||||||||
| FirstName: | KITA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5957 W 75TH ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900451609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105670037 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12021 WILMINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5622954617 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2016 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 586627 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.