Basic Information
| Provider Information | |||||||||
| NPI: | 1881283042 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAVELA | ||||||||
| FirstName: | MARYANN | ||||||||
| MiddleName: | S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 W BROADWAY STE 800 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921013546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774182978 | ||||||||
| FaxNumber: | 8665002186 | ||||||||
| Practice Location | |||||||||
| Address1: | 14238 SARANAC LN | ||||||||
| Address2: | |||||||||
| City: | SYLMAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913421435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184850888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2021 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | CA | N | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.