Provider Demographics
NPI:1386133593
Name:FANOUS, MAURINA KRYSTAL
Entity type:Individual
Prefix:
First Name:MAURINA
Middle Name:KRYSTAL
Last Name:FANOUS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8028 4TH ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-3606
Mailing Address - Country:US
Mailing Address - Phone:562-728-3131
Mailing Address - Fax:
Practice Address - Street 1:221 E WALNUT ST STE 134
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1554
Practice Address - Country:US
Practice Address - Phone:626-377-9596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
CA19688171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst