Healthcare Provider Details

I. General information

NPI: 1447606694
Provider Name (Legal Business Name): MS. ORIEL ASHLEY RENAULT NISSIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2016
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W CARROLL AVE FL 1
GLENDORA CA
91741-4208
US

IV. Provider business mailing address

1041 W BADILLO ST STE 104
COVINA CA
91722-4194
US

V. Phone/Fax

Practice location:
  • Phone: 626-963-4124
  • Fax:
Mailing address:
  • Phone: 626-732-8319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA177711
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: