Provider Demographics
NPI:1700119195
Name:DE LEON, MIA (NP)
Entity type:Individual
Prefix:MS
First Name:MIA
Middle Name:
Last Name:DE LEON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:
Other - Last Name:DE LEON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:960 S WESTLAKE BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-3162
Mailing Address - Country:US
Mailing Address - Phone:805-379-5970
Mailing Address - Fax:805-379-5211
Practice Address - Street 1:960 S WESTLAKE BLVD STE 208
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-3162
Practice Address - Country:US
Practice Address - Phone:805-379-5970
Practice Address - Fax:805-379-5211
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA497626363L00000X
CANP9810207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology