Provider Demographics
NPI:1093219172
Name:ALFONSO, MIRADEI JIL MALLARI (RN, BSN)
Entity Type:Individual
Prefix:
First Name:MIRADEI JIL
Middle Name:MALLARI
Last Name:ALFONSO
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3612 ASTRAL DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-3508
Mailing Address - Country:US
Mailing Address - Phone:650-892-4847
Mailing Address - Fax:
Practice Address - Street 1:3612 ASTRAL DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827-3508
Practice Address - Country:US
Practice Address - Phone:650-892-4847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95086635163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse