Healthcare Provider Details

I. General information

NPI: 1538084272
Provider Name (Legal Business Name): MARY KRISTIN MICU AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S BUENA VISTA ST
BURBANK CA
91505-4809
US

IV. Provider business mailing address

931 N HOLLYWOOD WAY UNIT 2010
BURBANK CA
91505-2816
US

V. Phone/Fax

Practice location:
  • Phone: 818-843-5111
  • Fax:
Mailing address:
  • Phone: 747-322-1995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number839051
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95040572
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: