Provider Demographics
NPI:1548514565
Name:MODIRROUSTA, MARYAM (CNM, NP)
Entity type:Individual
Prefix:MRS
First Name:MARYAM
Middle Name:
Last Name:MODIRROUSTA
Suffix:
Gender:F
Credentials:CNM, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18300 US HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2206
Mailing Address - Country:US
Mailing Address - Phone:706-242-2311
Mailing Address - Fax:760-946-8875
Practice Address - Street 1:18300 US HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2206
Practice Address - Country:US
Practice Address - Phone:706-242-2311
Practice Address - Fax:760-946-8875
Is Sole Proprietor?:No
Enumeration Date:2012-10-29
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANMW1949367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife