Provider Demographics
NPI:1861670408
Name:SOBA, MIRIAN ANTONIA
Entity Type:Individual
Prefix:MISS
First Name:MIRIAN
Middle Name:ANTONIA
Last Name:SOBA
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 1:123 W MANCHESTER BLVD RM 231B
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1753
Mailing Address - Country:US
Mailing Address - Phone:310-419-5308
Mailing Address - Fax:310-330-7010
Practice Address - Street 1:123 W MANCHESTER BLVD RM 231B
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1753
Practice Address - Country:US
Practice Address - Phone:310-419-5308
Practice Address - Fax:310-330-7010
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA509171163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management