Healthcare Provider Details

I. General information

NPI: 1316597909
Provider Name (Legal Business Name): GENEVIEVE BETIS MIRANDA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1161 E COVINA BLVD
COVINA CA
91724-1523
US

IV. Provider business mailing address

1161 E COVINA BLVD
COVINA CA
91724-1523
US

V. Phone/Fax

Practice location:
  • Phone: 626-966-1632
  • Fax: 626-967-5158
Mailing address:
  • Phone: 626-966-1632
  • Fax: 626-967-5158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number804158
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: