Provider Demographics
NPI:1063529592
Name:LEIVA, ANGELINA LAROCO (NP)
Entity type:Individual
Prefix:
First Name:ANGELINA
Middle Name:LAROCO
Last Name:LEIVA
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 1:1548 NOEL CIR
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-3752
Mailing Address - Country:US
Mailing Address - Phone:805-583-5616
Mailing Address - Fax:
Practice Address - Street 1:MOBILE MEDICAL & NURSING, INC.
Practice Address - Street 2:4161 WEST KLING STREET, # 16
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505
Practice Address - Country:US
Practice Address - Phone:818-843-5225
Practice Address - Fax:818-843-5224
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP15295363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP15295OtherNP LICENSE