Provider Demographics
NPI:1063591576
Name:MAITEN, JILL E (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:E
Last Name:MAITEN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11272 LAMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-5323
Mailing Address - Country:US
Mailing Address - Phone:714-636-3144
Mailing Address - Fax:714-636-8703
Practice Address - Street 1:2701 ATLANTIC AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2701
Practice Address - Country:US
Practice Address - Phone:562-989-8449
Practice Address - Fax:562-989-8679
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL529329363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA529329OtherNURSE PRACTITIONER