Healthcare Provider Details

I. General information

NPI: 1760142244
Provider Name (Legal Business Name): LIEZLE AREVALO CRNA PROFESSIONAL NURSING ANESTHESIA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2021
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E WASHINGTON ST STE 155
COLTON CA
92324-4196
US

IV. Provider business mailing address

PO BOX 3129
TORRANCE CA
90510-3129
US

V. Phone/Fax

Practice location:
  • Phone: 909-370-2190
  • Fax:
Mailing address:
  • Phone: 310-792-3914
  • Fax: 855-898-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MS. LIEZLE AREVALO
Title or Position: PRESIDENT
Credential: CRNA
Phone: 310-792-3914