Healthcare Provider Details

I. General information

NPI: 1366982688
Provider Name (Legal Business Name): SAMAR MROUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 ARIOUS WAY
LANCASTER CA
93536-8419
US

IV. Provider business mailing address

3915 CALLE VALLE VIS
NEWBURY PARK CA
91320-1939
US

V. Phone/Fax

Practice location:
  • Phone: 661-886-8852
  • Fax: 661-206-8655
Mailing address:
  • Phone: 805-390-3943
  • Fax: 805-309-2376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number70279
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number233953
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: