Healthcare Provider Details

I. General information

NPI: 1750176095
Provider Name (Legal Business Name): IRESHA LINDA CIOCO PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15106 FOX RIDGE DR
FONTANA CA
92336-0205
US

IV. Provider business mailing address

15106 FOX RIDGE DR
FONTANA CA
92336-0205
US

V. Phone/Fax

Practice location:
  • Phone: 650-703-3000
  • Fax:
Mailing address:
  • Phone: 650-703-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number95034016
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: