Provider Demographics
NPI:1336835586
Name:OLMEDO, NATIVIDAD
Entity type:Individual
Prefix:
First Name:NATIVIDAD
Middle Name:
Last Name:OLMEDO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15556 VANOWEN ST APT 21
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-5146
Mailing Address - Country:US
Mailing Address - Phone:323-944-9316
Mailing Address - Fax:
Practice Address - Street 1:12021 WILMINGTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3019
Practice Address - Country:US
Practice Address - Phone:424-454-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-12
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
172V00000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker