Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 21556 | CA |
NPI | 1003187915 |
---|---|
Provider Name | Ms. Mariana Concepcion Moualem |
First Address | Los Angeles, CA 90029 |
Second Address | San Bernardino, CA 92411-1354 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2012 |
Last Update Date | 17/10/2018 |