Provider Demographics
NPI:1588014476
Name:MATHEW, RENI ROY (NP)
Entity Type:Individual
Prefix:MRS
First Name:RENI
Middle Name:ROY
Last Name:MATHEW
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9810 LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-5818
Mailing Address - Country:US
Mailing Address - Phone:714-679-5830
Mailing Address - Fax:
Practice Address - Street 1:4059 E OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-3330
Practice Address - Country:US
Practice Address - Phone:323-881-2615
Practice Address - Fax:323-881-2615
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004073363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily