MEDICARE: DENISE MAO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	808314	CA
2	363LF0000X	Family Nurse Practitioner	95006508	CA

General Provider Information

NPI Number	:	1922588011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE MAO

Provider Business Mailing Address
First Line	:	11234 ANDERSON ST RM 4438
Second Line	:
City	:	LOMA LINDA
State	:	CA
Zip	:	92354-2804
Country	:	US
Telephone Number	:	909-630-6844
Fax Number	:	909-558-0885

Provider Business Practice Location Address
First Line	:	11234 ANDERSON ST RM 4438
Second Line	:
City	:	LOMA LINDA
State	:	CA
Zip	:	92354-2804
Country	:	US
Telephone Number	:	909-630-6844
Fax Number	:	909-558-0885

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2018
Last Update Date	:	08/17/2018

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Directions to “ DENISE MAO ” Practice Location

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