Healthcare Provider Details

I. General information

NPI: 1760171904
Provider Name (Legal Business Name): SELINA VILLARREAL GONZALEZ NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1965 W 24TH ST
YUMA AZ
85364-6244
US

IV. Provider business mailing address

2400 S AVENUE A
YUMA AZ
85364-7127
US

V. Phone/Fax

Practice location:
  • Phone: 928-344-5774
  • Fax:
Mailing address:
  • Phone: 928-344-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number221654
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: