Provider Demographics
NPI:1013795129
Name:VALENCIA, MIRANDA ISABEL
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ISABEL
Last Name:VALENCIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16761 VIEWPOINT LN APT 323
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-4786
Mailing Address - Country:US
Mailing Address - Phone:559-223-7274
Mailing Address - Fax:
Practice Address - Street 1:1955 LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-5501
Practice Address - Country:US
Practice Address - Phone:562-625-2976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-19
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program