Provider Demographics
NPI:1912508821
Name:VALDEZ, MYLENE (NP)
Entity Type:Individual
Prefix:
First Name:MYLENE
Middle Name:
Last Name:VALDEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MYLENE
Other - Middle Name:LASOLA
Other - Last Name:SIDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6244 EL CAJON BLVD STE 29
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-3918
Mailing Address - Country:US
Mailing Address - Phone:888-628-6680
Mailing Address - Fax:
Practice Address - Street 1:6244 EL CAJON BLVD STE 29
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-3918
Practice Address - Country:US
Practice Address - Phone:888-628-6680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95015498363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily