Provider Demographics
NPI:1508223256
Name:TELASCO-MAURISSEAU, INGRID (ARNP)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:TELASCO-MAURISSEAU
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:STE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:888-562-5442
Mailing Address - Fax:844-861-1929
Practice Address - Street 1:13121 SW 45TH DR
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-3159
Practice Address - Country:US
Practice Address - Phone:754-234-8983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9211750363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily