Provider Demographics
NPI:1215398474
Name:TOVALIN, MIRNA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MIRNA
Middle Name:
Last Name:TOVALIN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16101 GLENCOVE DR
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-6515
Mailing Address - Country:US
Mailing Address - Phone:626-322-4204
Mailing Address - Fax:
Practice Address - Street 1:16404 COLIMA RD STE FL1
Practice Address - Street 2:
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-5502
Practice Address - Country:US
Practice Address - Phone:626-581-8330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95003844363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily