Basic Information
| Provider Information | |||||||||
| NPI: | 1902364441 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARA | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 817 S MAIN ST STE D | ||||||||
| Address2: | |||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928823407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513398459 | ||||||||
| FaxNumber: | 9513398461 | ||||||||
| Practice Location | |||||||||
| Address1: | 309 W BEVERLY BLVD | ||||||||
| Address2: | |||||||||
| City: | MONTEBELLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906404308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237261222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2019 | ||||||||
| LastUpdateDate: | 03/04/2019 | ||||||||
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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 | 363LA2100X | 95009403 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.