Healthcare Provider Details

I. General information

NPI: 1164271912
Provider Name (Legal Business Name): AVA MURIELLE HANLYN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1851 N RIVERSIDE AVE
RIALTO CA
92376-8069
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 909-874-2371
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP95026913
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: