Basic Information
| Provider Information | |||||||||
| NPI: | 1548854458 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPOS | ||||||||
| FirstName: | MAYRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12626 LEWIS AVE | ||||||||
| Address2: | |||||||||
| City: | CHINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917103392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098034108 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1900 E SLAUSON AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902552725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884999303 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2021 | ||||||||
| LastUpdateDate: | 02/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95014698 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.