Healthcare Provider Details

I. General information

NPI: 1407583453
Provider Name (Legal Business Name): MAIRA REYNOSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2022
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8945 GOLF LINKS RD
OAKLAND CA
94605-4124
US

IV. Provider business mailing address

1404 LAUREN DR
PETALUMA CA
94954-3642
US

V. Phone/Fax

Practice location:
  • Phone: 317-510-1444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number95175973
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: