Healthcare Provider Details

I. General information

NPI: 1871098509
Provider Name (Legal Business Name): MARIA PROVENCHER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5638 LAKE MURRAY BLVD STE 332
LA MESA CA
91942-1929
US

IV. Provider business mailing address

5638 LAKE MURRAY BLVD STE 332
LA MESA CA
91942-1929
US

V. Phone/Fax

Practice location:
  • Phone: 619-481-8691
  • Fax:
Mailing address:
  • Phone: 619-481-8691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: