Provider Demographics
NPI:1154688612
Name:GULRAIZ, MARYAM (PMHNP-BC, FNP-C)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:GULRAIZ
Suffix:
Gender:F
Credentials:PMHNP-BC, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26632 TOWNE CENTRE DR STE 300
Mailing Address - Street 2:
Mailing Address - City:FOOTHILL RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92610-2814
Mailing Address - Country:US
Mailing Address - Phone:949-620-6397
Mailing Address - Fax:
Practice Address - Street 1:26632 TOWNE CENTRE DR STE 300
Practice Address - Street 2:
Practice Address - City:FOOTHILL RANCH
Practice Address - State:CA
Practice Address - Zip Code:92610-2814
Practice Address - Country:US
Practice Address - Phone:949-620-6397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003180363LF0000X, 363LP0808X
WAAP61517818363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily