Provider Demographics
NPI:1831717735
Name:VALENZUELA, MALINDA MARIAN
Entity type:Individual
Prefix:
First Name:MALINDA
Middle Name:MARIAN
Last Name:VALENZUELA
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:PO BOX 9865
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92375-3065
Mailing Address - Country:US
Mailing Address - Phone:909-653-9775
Mailing Address - Fax:
Practice Address - Street 1:126 AVOCADO AVE STE 106
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2605
Practice Address - Country:US
Practice Address - Phone:951-943-7212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015189363LF0000X
CA643704163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1396108403Medicaid