Provider Demographics
NPI:1730392754
Name:KONIAN, KOUASSI (NP)
Entity type:Individual
Prefix:
First Name:KOUASSI
Middle Name:
Last Name:KONIAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:MR
Other - First Name:KOUASSI
Other - Middle Name:
Other - Last Name:KONIAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:5822 CONIFER ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91377
Mailing Address - Country:US
Mailing Address - Phone:818-468-5669
Mailing Address - Fax:
Practice Address - Street 1:450 BAUCHET ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-2907
Practice Address - Country:US
Practice Address - Phone:295-888-4569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15576261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service