Basic Information
| Provider Information | |||||||||
| NPI: | 1699294827 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIRANDA | ||||||||
| FirstName: | MAYRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | L.V.N | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2236 BRODERICK AVE | ||||||||
| Address2: | |||||||||
| City: | DUARTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910103509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264987047 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 902 S MYRTLE AVE | ||||||||
| Address2: | |||||||||
| City: | MONROVIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910163427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262545000 | ||||||||
| FaxNumber: | 6262941079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2017 | ||||||||
| LastUpdateDate: | 09/19/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 693049 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.