Healthcare Provider Details

I. General information

NPI: 1851990550
Provider Name (Legal Business Name): FERNANDA MONTEON IBARRA AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2020
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30222 BELMONT CT
AGOURA HILLS CA
91301-4611
US

IV. Provider business mailing address

30222 BELMONT CT
AGOURA HILLS CA
91301-4611
US

V. Phone/Fax

Practice location:
  • Phone: 818-282-4054
  • Fax:
Mailing address:
  • Phone: 818-282-4054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberNP95012780
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP95012780
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberNP95012780
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: