Healthcare Provider Details

I. General information

NPI: 1689433971
Provider Name (Legal Business Name): LUZ MARIA ARELLANO PONCIANO B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11187 DE FOE AVE
PACOIMA CA
91331-1954
US

IV. Provider business mailing address

14806 ORO GRANDE ST
SYLMAR CA
91342-4641
US

V. Phone/Fax

Practice location:
  • Phone: 818-898-0223
  • Fax: 818-361-5384
Mailing address:
  • Phone: 818-602-0372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number123456
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: