Basic Information
| Provider Information | |||||||||
| NPI: | 1285994442 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMACHO | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | RN, MSN, PNP-PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4650 W SUNSET BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900276062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233612322 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4650 W SUNSET BLVD | ||||||||
| Address2: | LOS ANGELES | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900276062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5623612322 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2012 | ||||||||
| LastUpdateDate: | 05/22/2012 | ||||||||
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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 | 163WP0200X | 556433 | CA | N | Nursing Service Providers | Registered Nurse | Pediatrics | 363LP0200X | 21166 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 364SP0200X | 3669 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | NPF21166 | 01 | CA | NURSE PRACTITIONER FURNISHING NUMBER | OTHER | MC2615891 | 01 | CA | DEA | OTHER |