Healthcare Provider Details

I. General information

NPI: 1861883654
Provider Name (Legal Business Name): MARY JO SORIANO MIZRACHI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2015
Last Update Date: 02/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19618 E 50TH DR
DENVER CO
80249-8469
US

IV. Provider business mailing address

19618 E 50TH DR
DENVER CO
80249-8469
US

V. Phone/Fax

Practice location:
  • Phone: 303-931-2891
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN 0331153
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: