Healthcare Provider Details

I. General information

NPI: 1518623990
Provider Name (Legal Business Name): FATIMA PONIO GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 MOSS ST
CHULA VISTA CA
91911-2005
US

IV. Provider business mailing address

330 MOSS ST
CHULA VISTA CA
91911-2005
US

V. Phone/Fax

Practice location:
  • Phone: 619-426-6310
  • Fax:
Mailing address:
  • Phone: 619-426-6310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number581908
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: