Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | A64140 | CA |
N | 111NI0900X | Internist | A64140 | CA |
N | 207RC0200X | Critical Care Medicine | A64140 | CA |
Y | 207RP1001X | Pulmonary Disease | A64140 | CA |
NPI | 1023043775 |
---|---|
Provider Name | Dr. Colleen Lucy Channick |
First Address | Los Angeles, CA 90045-5631 |
Second Address | Santa Monica, CA 90404-1279 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/07/2006 |
Last Update Date | 05/07/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00A641400 | (05) | CA |
G73969 | (02) | CA |