Provider Demographics
NPI:1043523707
Name:REZVANI, MISSRA (NP)
Entity type:Individual
Prefix:
First Name:MISSRA
Middle Name:
Last Name:REZVANI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 W STEWART DR
Mailing Address - Street 2:STE 410
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3854
Mailing Address - Country:US
Mailing Address - Phone:714-639-9401
Mailing Address - Fax:
Practice Address - Street 1:1010 W LA VETA AVE
Practice Address - Street 2:STE 750
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4300
Practice Address - Country:US
Practice Address - Phone:714-361-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19140363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19140OtherMEDICAL LICENSE (NP)
CA670627OtherMEDICAL LICENSE (RN)