Healthcare Provider Details

I. General information

NPI: 1679703136
Provider Name (Legal Business Name): PROMILA M MAHTAB R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2009
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 E CESAR CHAVEZ BLVD
FRESNO CA
93702-3604
US

IV. Provider business mailing address

2620 RICHERT AVE
CLOVIS CA
93611
US

V. Phone/Fax

Practice location:
  • Phone: 559-453-1008
  • Fax:
Mailing address:
  • Phone: 559-292-0420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number499674
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: