Basic Information
| Provider Information | |||||||||
| NPI: | 1437356391 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOMOND | ||||||||
| FirstName: | MARITZA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TYRRELL | ||||||||
| OtherFirstName: | MARITZA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9808 VENICE BLVD | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902322732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102539494 | ||||||||
| FaxNumber: | 3102539495 | ||||||||
| Practice Location | |||||||||
| Address1: | 9808 VENICE BLVD | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902322732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102539494 | ||||||||
| FaxNumber: | 3102539495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 481787 | CA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 481787 | 01 | CA | REGISTERED NURSING LIC | OTHER |