Provider Demographics
NPI:1447401930
Name:METILDI, MARY (RN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:METILDI
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23591 EL TORO
Mailing Address - Street 2:155
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92691
Mailing Address - Country:US
Mailing Address - Phone:949-899-7717
Mailing Address - Fax:
Practice Address - Street 1:19442 SUNRAY LN UNIT 104
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-6403
Practice Address - Country:US
Practice Address - Phone:949-837-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA403116163W00000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163W00000XNursing Service ProvidersRegistered Nurse