1063616779 NPI number — MRS. LAURA SUSAN VAN ROSSUM MSN, CRNA

Table of content: MRS. LAURA SUSAN VAN ROSSUM MSN, CRNA (NPI 1063616779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063616779 NPI number — MRS. LAURA SUSAN VAN ROSSUM MSN, CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN ROSSUM
Provider First Name:
LAURA
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSN, CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YASSANYE
Provider Other First Name:
LAURA
Provider Other Middle Name:
SUSAN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063616779
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5601 DE SOTO AVE
Provider Second Line Business Mailing Address:
DEPT OF ANESTHESIA
Provider Business Mailing Address City Name:
WOODLAND HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91367-6701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-719-2695
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5601 DE SOTO AVE
Provider Second Line Business Practice Location Address:
DEPT OF ANESTHESIA
Provider Business Practice Location Address City Name:
WOODLAND HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91367-6701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-719-2695
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/14/2007

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: 367500000X , with the licence number:  72431 , 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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