Healthcare Provider Details

I. General information

NPI: 1932628005
Provider Name (Legal Business Name): JODI ANN MAINWAL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2017
Last Update Date: 09/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 TECHNOLOGY DR # MS 41
IRVINE CA
92618-2302
US

IV. Provider business mailing address

17638 WILDFLOWER PL
CHINO HILLS CA
91709-3264
US

V. Phone/Fax

Practice location:
  • Phone: 949-923-3200
  • Fax: 949-923-3520
Mailing address:
  • Phone: 951-235-3013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number494337
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WH0500X
TaxonomyHemodialysis Registered Nurse
License Number494337
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code163WN0300X
TaxonomyNephrology Registered Nurse
License Number494337
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: