Provider Demographics
NPI:1154165884
Name:MORA, GISELLE MIRIAM
Entity type:Individual
Prefix:
First Name:GISELLE
Middle Name:MIRIAM
Last Name:MORA
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 1:5964 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003-1145
Mailing Address - Country:US
Mailing Address - Phone:323-637-1099
Mailing Address - Fax:323-637-1099
Practice Address - Street 1:5964 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-1145
Practice Address - Country:US
Practice Address - Phone:323-637-1099
Practice Address - Fax:323-637-1099
Is Sole Proprietor?:No
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program