Healthcare Provider Details

I. General information

NPI: 1063793065
Provider Name (Legal Business Name): FIDES P ESCOBAL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: FIDES P ESCOBAL FNP

II. Dates (important events)

Enumeration Date: 09/02/2011
Last Update Date: 09/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17264 FOOTHILL BLVD STE AB
FONTANA CA
92335-9050
US

IV. Provider business mailing address

PO BOX 8188
REDLANDS CA
92375-1388
US

V. Phone/Fax

Practice location:
  • Phone: 909-428-3900
  • Fax: 909-428-3903
Mailing address:
  • Phone: 909-790-5071
  • Fax: 909-790-5774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20805
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: