Healthcare Provider Details

I. General information

NPI: 1922244532
Provider Name (Legal Business Name): SUSAN MAUD MASON NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2009
Last Update Date: 01/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44456 PENBROOK LN
TEMECULA CA
92592-5625
US

IV. Provider business mailing address

44456 PENBROOK LN
TEMECULA CA
92592-5625
US

V. Phone/Fax

Practice location:
  • Phone: 310-634-7373
  • Fax: 951-303-2371
Mailing address:
  • Phone: 310-634-7373
  • Fax: 951-303-2371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number613017
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: