Healthcare Provider Details

I. General information

NPI: 1295922045
Provider Name (Legal Business Name): MARY JANE RELAMPAGOS MANCUSO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS MARY JANE CORPUS RELAMPAGOS

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 10/23/2021
Certification Date: 10/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 ALTA AVE SUITE #110
UPLAND CA
91786-2800
US

IV. Provider business mailing address

1759 CREBS WAY
UPLAND CA
91784-9297
US

V. Phone/Fax

Practice location:
  • Phone: 626-922-8060
  • Fax:
Mailing address:
  • Phone: 626-922-8060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number545344
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: