Healthcare Provider Details

I. General information

NPI: 1962573105
Provider Name (Legal Business Name): ANNA MARIE PONCE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

491 E ALESSANDRO BLVD
RIVERSIDE CA
92508-6071
US

IV. Provider business mailing address

872 HOMESTEAD RD
CORONA CA
92878-9759
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone: 714-395-3783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number516348
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95017064
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: