Healthcare Provider Details

I. General information

NPI: 1588190664
Provider Name (Legal Business Name): VANESSA GUZMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2017
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82151 AVENUE 42 STE 100
INDIO CA
92203-9313
US

IV. Provider business mailing address

8780 19TH ST # 300
ALTA LOMA CA
91701-4608
US

V. Phone/Fax

Practice location:
  • Phone: 442-224-6968
  • Fax:
Mailing address:
  • Phone: 617-528-9406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA54785
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: