Provider Demographics
NPI:1013451731
Name:MISA, MARIA FATIMA GEORGIA FERNANDEZ
Entity Type:Individual
Prefix:
First Name:MARIA FATIMA GEORGIA
Middle Name:FERNANDEZ
Last Name:MISA
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARIA FATIMA GEORGIA
Other - Middle Name:MISA
Other - Last Name:THIEME
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP-C
Mailing Address - Street 1:5722 MONTE VISTA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-3428
Mailing Address - Country:US
Mailing Address - Phone:714-473-4051
Mailing Address - Fax:
Practice Address - Street 1:5722 MONTE VISTA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-3428
Practice Address - Country:US
Practice Address - Phone:714-473-4051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-14
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004318363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily