Healthcare Provider Details

I. General information

NPI: 1184965709
Provider Name (Legal Business Name): MICHAEL JOSEPH NICANDRO NEVAREZ DNP, RN, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2013
Last Update Date: 06/25/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 S LEMON AVE # 9892
WALNUT CA
91789-2706
US

IV. Provider business mailing address

340 S LEMON AVE # 9892
WALNUT CA
91789-2706
US

V. Phone/Fax

Practice location:
  • Phone: 415-403-2156
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95015602
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number807833
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: