Healthcare Provider Details

I. General information

NPI: 1760304539
Provider Name (Legal Business Name): IRIS ANABELL TEJADA FUENTES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 WINDSOR DR
SAN BERNARDINO CA
92404-5416
US

IV. Provider business mailing address

12683 DREW CT
MORENO VALLEY CA
92553-5619
US

V. Phone/Fax

Practice location:
  • Phone: 909-361-6470
  • Fax:
Mailing address:
  • Phone: 951-647-6709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: