Provider Demographics
NPI:1548735715
Name:MARA, VIRGINIA ANNE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:ANNE
Last Name:MARA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:ANNE
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2441 W LA PALMA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-2658
Mailing Address - Country:US
Mailing Address - Phone:657-282-6356
Mailing Address - Fax:
Practice Address - Street 1:2441 W LA PALMA AVE STE 100
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2658
Practice Address - Country:US
Practice Address - Phone:657-282-6356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029055163W00000X
CA95010219363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse