Healthcare Provider Details

I. General information

NPI: 1336761378
Provider Name (Legal Business Name): MIRIAM ETIENNE DNP, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

666 EDGEWATER BLVD # F-101
FOSTER CITY CA
94404-2872
US

IV. Provider business mailing address

666 EDGEWATER BLVD # F-101
FOSTER CITY CA
94404-2872
US

V. Phone/Fax

Practice location:
  • Phone: 347-628-0147
  • Fax:
Mailing address:
  • Phone: 347-628-0147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2019055030
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: