Provider Demographics
NPI:1568005833
Name:MUNIZ, JENNIFER MARINA
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARINA
Last Name:MUNIZ
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 1:8179 BRANDING IRON LN
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-6613
Mailing Address - Country:US
Mailing Address - Phone:626-392-2191
Mailing Address - Fax:
Practice Address - Street 1:1800 WESTERN AVE STE 305
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1354
Practice Address - Country:US
Practice Address - Phone:909-880-9993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-19
Last Update Date:2019-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012989363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily