Provider Demographics
NPI:1184903148
Name:VILLA, MAIRA (BA)
Entity type:Individual
Prefix:MISS
First Name:MAIRA
Middle Name:
Last Name:VILLA
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 W COSTNER ST
Mailing Address - Street 2:
Mailing Address - City:FARMERSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93223-1406
Mailing Address - Country:US
Mailing Address - Phone:559-303-9174
Mailing Address - Fax:
Practice Address - Street 1:3467 W SHAW AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3223
Practice Address - Country:US
Practice Address - Phone:559-271-3096
Practice Address - Fax:559-274-0292
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA941719862171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator