Healthcare Provider Details

I. General information

NPI: 1902629348
Provider Name (Legal Business Name): THERESE MARIEL FONSECA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43322 GINGHAM AVE
LANCASTER CA
93535-4576
US

IV. Provider business mailing address

40301 PRESTON RD
PALMDALE CA
93551-5357
US

V. Phone/Fax

Practice location:
  • Phone: 661-874-4050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95185009
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95032530
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: