Basic Information
| Provider Information | |||||||||
| NPI: | 1891197232 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKIERNAN | ||||||||
| FirstName: | MAIRA | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 137 | ||||||||
| Address2: | |||||||||
| City: | DUARTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910090137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263583866 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1556 S SULTANA AVE | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917614238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094186936 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2014 | ||||||||
| LastUpdateDate: | 09/29/2014 | ||||||||
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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 | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.