Provider Demographics
NPI:1871244947
Name:DE MARIA, MICHELLE (ACNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DE MARIA
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 BAGLEY AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-7402
Mailing Address - Country:US
Mailing Address - Phone:619-339-0923
Mailing Address - Fax:
Practice Address - Street 1:8700 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1804
Practice Address - Country:US
Practice Address - Phone:310-423-3277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95019551363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95019551OtherCA STATE ACNP LICENSE