Healthcare Provider Details

I. General information

NPI: 1932929353
Provider Name (Legal Business Name): EMMANUEL SEVILLA PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1259 CAMINO CARMELO UNIT 121
CHULA VISTA CA
91913-3389
US

IV. Provider business mailing address

1259 CAMINO CARMELO UNIT 121
CHULA VISTA CA
91913-3389
US

V. Phone/Fax

Practice location:
  • Phone: 619-944-4475
  • Fax:
Mailing address:
  • Phone: 619-944-4475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95032477
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: