Healthcare Provider Details

I. General information

NPI: 1396326856
Provider Name (Legal Business Name): MIA KATHLEEN MAURICIO TABAGO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2021
Last Update Date: 07/11/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1832 ALPINE BLVD STE B
ALPINE CA
91901-2107
US

IV. Provider business mailing address

1832 ALPINE BLVD STE B
ALPINE CA
91901-2107
US

V. Phone/Fax

Practice location:
  • Phone: 619-326-4445
  • Fax:
Mailing address:
  • Phone: 619-326-4445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95040457
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number95226737
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: