Provider Demographics
NPI:1942658851
Name:VERGARA, MARIANA (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:MARIANA
Middle Name:
Last Name:VERGARA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S LASKY DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-3615
Mailing Address - Country:US
Mailing Address - Phone:310-897-1440
Mailing Address - Fax:
Practice Address - Street 1:435 N BEDFORD DR STE 402
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4334
Practice Address - Country:US
Practice Address - Phone:310-897-1440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003599363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily