Healthcare Provider Details

I. General information

NPI: 1528668589
Provider Name (Legal Business Name): MARISSA MONIQUE MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

572 N ARROWHEAD AVE
SAN BERNARDINO CA
92401-1251
US

IV. Provider business mailing address

572 N ARROWHEAD AVE
SAN BERNARDINO CA
92401-1251
US

V. Phone/Fax

Practice location:
  • Phone: 714-328-4258
  • Fax:
Mailing address:
  • Phone: 714-328-4258
  • 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: