Basic Information
| Provider Information | |||||||||
| NPI: | 1508223256 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TELASCO-MAURISSEAU | ||||||||
| FirstName: | INGRID | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 OCEANGATE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885625442 | ||||||||
| FaxNumber: | 8448611929 | ||||||||
| Practice Location | |||||||||
| Address1: | 13121 SW 45TH DR | ||||||||
| Address2: | |||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330273159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7542348983 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2016 | ||||||||
| LastUpdateDate: | 09/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 9211750 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.