Healthcare Provider Details

I. General information

NPI: 1558046151
Provider Name (Legal Business Name): MICHELLE JUANENGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31772 CASINO DR STE B
LAKE ELSINORE CA
92530-4502
US

IV. Provider business mailing address

31772 CASINO DR STE B
LAKE ELSINORE CA
92530-4502
US

V. Phone/Fax

Practice location:
  • Phone: 951-674-9400
  • Fax:
Mailing address:
  • Phone: 951-674-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCMPSS-BKGOPA
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: