Provider Demographics
NPI:1336673409
Name:POGGIO, MAYRA ALEJANDRA LARISSA
Entity Type:Individual
Prefix:MISS
First Name:MAYRA
Middle Name:ALEJANDRA LARISSA
Last Name:POGGIO
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 1:160 W COCHRAN ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-6215
Mailing Address - Country:US
Mailing Address - Phone:180-558-3227
Mailing Address - Fax:
Practice Address - Street 1:160 W COCHRAN ST
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-6215
Practice Address - Country:US
Practice Address - Phone:180-558-3227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT17222251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare