Provider Demographics
NPI:1437356391
Name:FOMOND, MARITZA (RN)
Entity Type:Individual
Prefix:
First Name:MARITZA
Middle Name:
Last Name:FOMOND
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARITZA
Other - Middle Name:
Other - Last Name:TYRRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9808 VENICE BLVD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-2732
Mailing Address - Country:US
Mailing Address - Phone:310-253-9494
Mailing Address - Fax:310-253-9495
Practice Address - Street 1:9808 VENICE BLVD
Practice Address - Street 2:SUITE 700
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2732
Practice Address - Country:US
Practice Address - Phone:310-253-9494
Practice Address - Fax:310-253-9495
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA481787163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA481787OtherREGISTERED NURSING LIC