Basic Information
| Provider Information | |||||||||
| NPI: | 1124485438 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE GUZMAN | ||||||||
| FirstName: | MARY ANNTHONETTE | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 23454 GLENRIDGE DR | ||||||||
| Address2: | |||||||||
| City: | NEWHALL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913213955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187487066 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16260 VENTURA BLVD #600 | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189861977 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2016 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 13092 | CA | N | Other Service Providers | Specialist |
No ID Information.