Healthcare Provider Details

I. General information

NPI: 1275289746
Provider Name (Legal Business Name): ALYVIAH DURHAM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2022
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 E FOOTHILL BLVD
GLENDORA CA
91740-4000
US

IV. Provider business mailing address

2363 1ST ST UNIT 25
LA VERNE CA
91750-5527
US

V. Phone/Fax

Practice location:
  • Phone: 626-852-3376
  • Fax:
Mailing address:
  • Phone: 217-827-7312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberPA60807
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: