Provider Demographics
NPI:1710557939
Name:ESTRADA, MARY (BSN, RN, PHN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ESTRADA
Suffix:
Gender:F
Credentials:BSN, RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13830 PENN ST
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90602-1947
Mailing Address - Country:US
Mailing Address - Phone:562-237-8108
Mailing Address - Fax:
Practice Address - Street 1:13830 PENN ST
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1947
Practice Address - Country:US
Practice Address - Phone:562-237-8108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA349548163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse