Healthcare Provider Details

I. General information

NPI: 1548080740
Provider Name (Legal Business Name): MYRANDA LESLEY KRIDER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2024
Last Update Date: 10/12/2024
Certification Date: 10/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9100 WILSHIRE BLVD
BEVERLY HILLS CA
90212-3415
US

IV. Provider business mailing address

9649 W OLYMPIC BLVD APT 4
BEVERLY HILLS CA
90212-3746
US

V. Phone/Fax

Practice location:
  • Phone: 424-777-0708
  • Fax:
Mailing address:
  • Phone: 760-780-8293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95031288
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: