Provider Demographics
NPI:1548857451
Name:ZARA, JUANA MAMISAY
Entity type:Individual
Prefix:
First Name:JUANA
Middle Name:MAMISAY
Last Name:ZARA
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JUANA
Other - Middle Name:RIVERA
Other - Last Name:MAMISAY
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3783 FAIRFAX WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-5250
Mailing Address - Country:US
Mailing Address - Phone:650-703-0640
Mailing Address - Fax:
Practice Address - Street 1:3783 FAIRFAX WAY
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-5250
Practice Address - Country:US
Practice Address - Phone:650-703-0640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-26
Last Update Date:2020-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207845164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse