Provider Demographics
NPI:1700119195
Name:DE LEON, MIA (NP)
Entity Type:Individual
Prefix:MS
First Name:MIA
Middle Name:
Last Name:DE LEON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:
Other - Last Name:DE LEON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:32144 AGOURA RD
Mailing Address - Street 2:STE 106
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-4040
Mailing Address - Country:US
Mailing Address - Phone:805-379-3376
Mailing Address - Fax:805-379-3267
Practice Address - Street 1:415 ROLLING OAKS DR STE 110
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-1030
Practice Address - Country:US
Practice Address - Phone:805-557-1740
Practice Address - Fax:805-557-1743
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA497626363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner