Provider Demographics
NPI:1043492143
Name:AREVALO, LIEZLE M (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:LIEZLE
Middle Name:M
Last Name:AREVALO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3129
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90510-3129
Mailing Address - Country:US
Mailing Address - Phone:310-792-3914
Mailing Address - Fax:855-898-4055
Practice Address - Street 1:900 E WASHINGTON ST STE 155
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-4196
Practice Address - Country:US
Practice Address - Phone:909-370-2190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA606141163W00000X
CA3568367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse