Healthcare Provider Details

I. General information

NPI: 1700487766
Provider Name (Legal Business Name): MICHELLE DE VELA PADRE AGACNP-BC, AGCNS, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2020
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 PENINSULA CTR STE E #303
ROLLING HILLS ESTATES CA
90274-3562
US

IV. Provider business mailing address

19305 HALLMARK LN
CERRITOS CA
90703-6841
US

V. Phone/Fax

Practice location:
  • Phone: 310-994-5679
  • Fax:
Mailing address:
  • Phone: 562-316-8487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number843396
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License Number4892
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95015659
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: