Healthcare Provider Details

I. General information

NPI: 1174206478
Provider Name (Legal Business Name): VIVIANA ANTUNEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 MARSHALL AVE
IMPERIAL CA
92251-9599
US

IV. Provider business mailing address

2387 SANDALWOOD DR
EL CENTRO CA
92243-3611
US

V. Phone/Fax

Practice location:
  • Phone: 760-550-6327
  • Fax:
Mailing address:
  • Phone: 760-234-5432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95025419
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: