Healthcare Provider Details

I. General information

NPI: 1174587091
Provider Name (Legal Business Name): MEGAN MARIE PARENT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4TH ST
FORT IRWIN CA
92310
US

IV. Provider business mailing address

76 GRENADA WAY
FORT IRWIN CA
92310-1721
US

V. Phone/Fax

Practice location:
  • Phone: 760-380-3185
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number89595
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: