Provider Demographics
NPI:1457797862
Name:FISHER, MARY LEONA (16/1964)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LEONA
Last Name:FISHER
Suffix:
Gender:F
Credentials:16/1964
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 PASEO DE LA SERENATA
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4351
Mailing Address - Country:US
Mailing Address - Phone:949-842-0569
Mailing Address - Fax:
Practice Address - Street 1:151 KALMUS DR STE K3
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5975
Practice Address - Country:US
Practice Address - Phone:714-384-3870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23452167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician