Provider Demographics
NPI:1871361774
Name:VILLANUEVA, MARIEL
Entity type:Individual
Prefix:
First Name:MARIEL
Middle Name:
Last Name:VILLANUEVA
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 1:6747 MUSK MALLOW CT
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-9165
Mailing Address - Country:US
Mailing Address - Phone:909-762-1932
Mailing Address - Fax:
Practice Address - Street 1:8920 WILSHIRE BLVD STE 327
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2003
Practice Address - Country:US
Practice Address - Phone:310-573-8947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027053363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily