Healthcare Provider Details

I. General information

NPI: 1174963177
Provider Name (Legal Business Name): MANJU KAUR CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2013
Last Update Date: 12/06/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3975 JACKSON ST
RIVERSIDE CA
92503-3901
US

IV. Provider business mailing address

3975 JACKSON ST
RIVERSIDE CA
92503-3901
US

V. Phone/Fax

Practice location:
  • Phone: 951-352-2092
  • Fax:
Mailing address:
  • Phone: 951-352-2092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number20914
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: