Healthcare Provider Details

I. General information

NPI: 1053980052
Provider Name (Legal Business Name): YLIANA PENALOSA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7755 CENTER AVE STE 630
HUNTINGTON BEACH CA
92647-9152
US

IV. Provider business mailing address

1736 W MONTECITO WAY
SAN DIEGO CA
92103-1263
US

V. Phone/Fax

Practice location:
  • Phone: 657-237-2450
  • Fax:
Mailing address:
  • Phone: 619-254-6669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95012667
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: