Provider Demographics
NPI:1922568294
Name:RENOLAYAN, MARIA MARTA VIRI (NP)
Entity Type:Individual
Prefix:MS
First Name:MARIA MARTA
Middle Name:VIRI
Last Name:RENOLAYAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:555 PAULARINO AVE APT L105
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3280
Mailing Address - Country:US
Mailing Address - Phone:562-881-5127
Mailing Address - Fax:
Practice Address - Street 1:3325 PALO VERDE AVE STE 203
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-4132
Practice Address - Country:US
Practice Address - Phone:562-421-8283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010961363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95010961OtherBOARD OF REGISTERED NURSING