Healthcare Provider Details

I. General information

NPI: 1073794210
Provider Name (Legal Business Name): MOLLY MEZA PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2007
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27512 CALLE ARROYO
SAN JUAN CAPISTRANO CA
92675-2748
US

IV. Provider business mailing address

27512 CALLE ARROYO
SAN JUAN CAPISTRANO CA
92675-2748
US

V. Phone/Fax

Practice location:
  • Phone: 949-248-2207
  • Fax: 949-248-2218
Mailing address:
  • Phone: 949-248-2207
  • Fax: 949-248-2218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN357292
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: