Healthcare Provider Details

I. General information

NPI: 1487573473
Provider Name (Legal Business Name): LEGACY MOBILE PRIMARY CARE, A NURSING P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

666 EDGEWATER BLVD APT 101
FOSTER CITY CA
94404-2849
US

IV. Provider business mailing address

2108 N ST # 16501
SACRAMENTO CA
95816-5712
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MIRIAM ETIENNE
Title or Position: PRESIDENT/CEO
Credential: DNP, FNP-BC
Phone: 347-628-0147