Healthcare Provider Details

I. General information

NPI: 1649073321
Provider Name (Legal Business Name): JESSICA ERIN VALTAIRO IGNACIO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2025
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 VICTORIA ST
COSTA MESA CA
92627-1995
US

IV. Provider business mailing address

216 RUSSELL AVE
FULLERTON CA
92833-2741
US

V. Phone/Fax

Practice location:
  • Phone: 949-574-3367
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95264776
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: