Basic Information
| Provider Information | |||||||||
| NPI: | 1124020243 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLUMPH | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 FLOWER ST | ||||||||
| Address2: | STE A | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912013000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186372000 | ||||||||
| FaxNumber: | 8182428761 | ||||||||
| Practice Location | |||||||||
| Address1: | 14901 RINALDI ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913451254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183658553 | ||||||||
| FaxNumber: | 8183654524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 04/14/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP6839 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 163W00000X | RN268367 | CA | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | RN268367 | 05 | CA | MEDICAID |