Kersey Fadduol

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

61229 Issued in CA

Practice address

1419 Ellsmere Ave
Los Angeles, CA 90019-3823

Phone

(805) 886-3148

NPI assigned

Mar 21, 2022

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: kersey.fadduol.1@19469.direct.athenahealth.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Brentview Medical Inc.

  dba Brentview Medical Urgent Care

  • Urgent Care Clinic/Center
  • Los Angeles, CA
  • NPI 1447581350
  Medicare reassignment
• Brentview Medical Inc.

  dba Brentview Medical Urgent Care

  • Urgent Care Clinic/Center
  • West Hollywood, CA
  • NPI 1326631177
  NPD
• Skinpeccable Inc.

  dba Concierge Medicine/LA

  • Clinic/Center
  • Los Angeles, CA
  • NPI 1194058578
  NPD
• BVM Therapy Inc.

  • Physical Therapy Clinic/Center
  • Los Angeles, CA
  • NPI 1912368358
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1647820800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1703203200000",
    "number": "1730838400",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11611 SAN VICENTE BLVD",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900495106"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1419 ELLSMERE AVE",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900193823",
            "telephone_number": "805-886-3148"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FADDUOL",
        "first_name": "KERSEY",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2022-03-21",
        "last_updated": "2023-12-22",
        "certification_date": "2022-08-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "CA",
            "license": "61229",
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "SOAP",
            "endpointTypeDescription": "SOAP URL",
            "endpoint": "https://careepicwest.kp.org:14430/Interconnect-prodcalgateway/wcf/epic.community.hie/xcpdrespondinggatewaysync.svc/scalceq",
            "affiliation": "Y",
            "endpointDescription": "Carequality",
            "affiliationName": "Southern California Permanente Medical Group",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "C-CDA",
            "address_1": "25825 Vermont Ave",
            "city": "Harbor City",
            "state": "CA",
            "country_code": "US",
            "postal_code": "907103518",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Lindsey Fackler
• Daniel Factor, LMFT #82033
• Reina Suzanne Factor, PHD
• Stephanie Facundo
• Diala Faddoul, MD
• Tanya Lee Fadely
• Teresa Mahoney Fadely, ACNP
• Angelique Fadera
• Gabrielle Fadly
• Marissa Faeldan-Suarez

• Physician Assistant in Los Angeles, CA
• Providers in Los Angeles, CA by specialty
• Physician Assistant in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 22, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.