Provider Demographics
NPI:1386913663
Name:HUMPHRIES, LINDA DOREEN (FNP)
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:DOREEN
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MISS
Other - First Name:LINDA
Other - Middle Name:DOREEN
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1045 W REDONDO BEACH BLVD
Mailing Address - Street 2:STE 575
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4191
Mailing Address - Country:US
Mailing Address - Phone:310-833-8536
Mailing Address - Fax:
Practice Address - Street 1:1141 W. REDONDO BEACH BLVD.
Practice Address - Street 2:SUITE 402
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247
Practice Address - Country:US
Practice Address - Phone:310-329-8633
Practice Address - Fax:310-329-8636
Is Sole Proprietor?:No
Enumeration Date:2011-12-15
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20737363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily