Healthcare Provider Details

I. General information

NPI: 1831910157
Provider Name (Legal Business Name): MYRA DE GUZMAN MANGUERRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2024
Last Update Date: 10/19/2024
Certification Date: 10/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 E CLINTON AVE
FRESNO CA
93703-2223
US

IV. Provider business mailing address

6951 E GARLAND AVE
FRESNO CA
93727-0905
US

V. Phone/Fax

Practice location:
  • Phone: 559-225-6100
  • Fax:
Mailing address:
  • Phone: 708-297-7254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number95182605
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: