Provider Demographics
NPI:1881162147
Name:ACLAN, MARYLOU
Entity type:Individual
Prefix:
First Name:MARYLOU
Middle Name:
Last Name:ACLAN
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 1:27074 HIDAWAY AVE UNIT 6
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91351-4121
Mailing Address - Country:US
Mailing Address - Phone:818-731-1657
Mailing Address - Fax:
Practice Address - Street 1:14400 OLIVE VIEW DR
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1436
Practice Address - Country:US
Practice Address - Phone:747-210-4324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010201207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine