Active NPI
Mary Boutros
- Gerontology Nurse Practitioner
- Los Angeles, CA
National Provider Identifier
1982588976
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Gerontology Nurse Practitioner
- License
- 95036011
- Practice address
- 11301 Wilshire Blvd
Los Angeles, CA 90073-1003 - Phone
- (310) 478-3711
- NPI assigned
- Aug 2, 2025
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Gerontology Nurse Practitioner | 363LG0600X | 95036011 | CA | Primary |
Addresses
Primary practice location
11301 Wilshire Blvd
Los Angeles, CA 90073-1003
Mailing address
3080 Charlotte St
Newbury Park, CA 91320-4451
Phone (805) 807-0743
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: No
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 95036011 | CA | MD | Gerontology Nurse Practitioner |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1754092800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1754092800000",
"number": "1982588976",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3080 CHARLOTTE ST",
"city": "NEWBURY PARK",
"state": "CA",
"postal_code": "913204451",
"telephone_number": "805-807-0743"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "11301 WILSHIRE BLVD",
"city": "LOS ANGELES",
"state": "CA",
"postal_code": "900731003",
"telephone_number": "310-478-3711"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BOUTROS",
"first_name": "MARY",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2025-08-02",
"last_updated": "2025-08-02",
"certification_date": "2025-08-02",
"status": "A"
},
"taxonomies": [
{
"code": "363LG0600X",
"taxonomy_group": "",
"desc": "Nurse Practitioner, Gerontology",
"state": "CA",
"license": "95036011",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Los Angeles, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 2, 2025; 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.