Healthcare Provider Details

I. General information

NPI: 1710616735
Provider Name (Legal Business Name): AMABELLE JUNE BLAZADO AGUELO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W TOWN AND COUNTRY RD STE 1300
ORANGE CA
92868-4654
US

IV. Provider business mailing address

7159 MYRTLE PL
FONTANA CA
92336-5706
US

V. Phone/Fax

Practice location:
  • Phone: 855-434-7763
  • Fax: 949-281-5550
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95021106
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: