Provider Demographics
NPI:1659365336
Name:MEYER, MARY J (FNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:J
Last Name:MEYER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JO
Other - Last Name:BROSS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8510 BALBOA BLVD
Mailing Address - Street 2:#150
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325
Mailing Address - Country:US
Mailing Address - Phone:818-654-3400
Mailing Address - Fax:818-654-3417
Practice Address - Street 1:191 S. BUENA VISTA
Practice Address - Street 2:#200
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505
Practice Address - Country:US
Practice Address - Phone:818-808-3509
Practice Address - Fax:310-496-0201
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14035363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q01402Medicare UPIN
CAQ01402Medicare UPIN