1194485532 NPI number — MIRANDA RENEE WILSON FNP

Table of content: MIRANDA RENEE WILSON FNP (NPI 1194485532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194485532 NPI number — MIRANDA RENEE WILSON FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
MIRANDA
Provider Middle Name:
RENEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194485532
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14051 ROBIN CREST LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHINO HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91709-4822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-751-5233
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
354 W FOOTHILL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLAREMONT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91711-2709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-624-1215
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/27/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  95019330 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 95019330 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com