Provider Demographics
NPI:1043905698
Name:URIBE, MARIAM IRMA
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:IRMA
Last Name:URIBE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 PINE AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-3039
Mailing Address - Country:US
Mailing Address - Phone:562-850-5520
Mailing Address - Fax:
Practice Address - Street 1:200 PINE AVE STE 400
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-3039
Practice Address - Country:US
Practice Address - Phone:562-850-5520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
390200000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program