Healthcare Provider Details

I. General information

NPI: 1134629629
Provider Name (Legal Business Name): MEGG U SOFESO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4310 ORANGE ST
RIVERSIDE CA
92501-3829
US

IV. Provider business mailing address

4310 ORANGE ST
RIVERSIDE CA
92501-3829
US

V. Phone/Fax

Practice location:
  • Phone: 951-781-6335
  • Fax: 951-781-6335
Mailing address:
  • Phone: 951-781-6335
  • Fax: 951-228-0052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number785560
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95008227
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: