Basic Information
| Provider Information | |||||||||
| NPI: | 1881154037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOYOLA | ||||||||
| FirstName: | MARY ANN | ||||||||
| MiddleName: | PIMENTEL | ||||||||
| NamePrefix: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PIMENTEL | ||||||||
| OtherFirstName: | MARY ANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4225 EXECUTIVE SQ STE 450 | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920378411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8588108000 | ||||||||
| FaxNumber: | 8582681911 | ||||||||
| Practice Location | |||||||||
| Address1: | 8851 CENTER DR STE 505 | ||||||||
| Address2: | |||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194613880 | ||||||||
| FaxNumber: | 6194613895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2019 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 95011408 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 95011408 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 95011408 | 01 | CA | LICENSE | OTHER |