Provider Demographics
NPI:1235986647
Name:DUROMOLA, MARYJANE
Entity type:Individual
Prefix:
First Name:MARYJANE
Middle Name:
Last Name:DUROMOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ABOSEDE
Other - Middle Name:MARY
Other - Last Name:RAJI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2605 E DATE PALM PASEO APT 2226
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-4672
Mailing Address - Country:US
Mailing Address - Phone:626-479-6482
Mailing Address - Fax:
Practice Address - Street 1:200 OCEANGATE STE 100
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4317
Practice Address - Country:US
Practice Address - Phone:909-361-9913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-02
Last Update Date:2024-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029802363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily