Provider Demographics
NPI:1003187915
Name:MOUALEM, MARIANA CONCEPCION (FNP)
Entity type:Individual
Prefix:MS
First Name:MARIANA
Middle Name:CONCEPCION
Last Name:MOUALEM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:908 NORTH ARDMORE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029
Mailing Address - Country:US
Mailing Address - Phone:626-632-8795
Mailing Address - Fax:
Practice Address - Street 1:1800 WESTERN AVE STE 305
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1354
Practice Address - Country:US
Practice Address - Phone:909-880-9993
Practice Address - Fax:909-880-9998
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-24
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21556363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily