Healthcare Provider Details

I. General information

NPI: 1114637568
Provider Name (Legal Business Name): MAI VUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2022
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7675 MISSION VALLEY RD
SAN DIEGO CA
92108-4429
US

IV. Provider business mailing address

5396 E TOWER AVE
FRESNO CA
93725-0933
US

V. Phone/Fax

Practice location:
  • Phone: 559-375-4488
  • Fax:
Mailing address:
  • Phone: 559-375-4488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number803216
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95022938
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: