Healthcare Provider Details

I. General information

NPI: 1619788007
Provider Name (Legal Business Name): NEYMI MIREYA MEMBRENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18612 SANTA ANA AVE
BLOOMINGTON CA
92316-2636
US

IV. Provider business mailing address

930 S MOUNT VERNON AVE
COLTON CA
92324-3928
US

V. Phone/Fax

Practice location:
  • Phone: 909-421-7120
  • Fax: 909-421-7128
Mailing address:
  • Phone: 562-852-3491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: