Healthcare Provider Details

I. General information

NPI: 1922568294
Provider Name (Legal Business Name): MARIA MARTA VIRI RENOLAYAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 03/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3325 PALO VERDE AVE STE 203
LONG BEACH CA
90808-4132
US

IV. Provider business mailing address

555 PAULARINO AVE APT L105
COSTA MESA CA
92626-3280
US

V. Phone/Fax

Practice location:
  • Phone: 562-421-8283
  • Fax:
Mailing address:
  • Phone: 562-881-5127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95010961
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: