Healthcare Provider Details

I. General information

NPI: 1124747084
Provider Name (Legal Business Name): VANESSA LISETTE MEJIA MACIAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2022
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

897 GRANITE DR
PASADENA CA
91101-3501
US

IV. Provider business mailing address

897 GRANITE DR
PASADENA CA
91101-3501
US

V. Phone/Fax

Practice location:
  • Phone: 626-993-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: