Healthcare Provider Details

I. General information

NPI: 1427774009
Provider Name (Legal Business Name): MIRIAM-NIRVANA NAGOULAT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 02/12/2026
Certification Date: 02/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7392 MAGNOLIA AVE
RIVERSIDE CA
92504-3861
US

IV. Provider business mailing address

3114 BELVEDERE AVE
HIGHLAND CA
92346-1614
US

V. Phone/Fax

Practice location:
  • Phone: 951-352-3330
  • Fax:
Mailing address:
  • Phone: 909-446-5965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95015160
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: