Healthcare Provider Details

I. General information

NPI: 1497272330
Provider Name (Legal Business Name): MONIQUE SHYDELL PANIAGUA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 ALTA RD
SAN DIEGO CA
92179-0001
US

IV. Provider business mailing address

11711 SAND CANYON RD
YUCAIPA CA
92399-1799
US

V. Phone/Fax

Practice location:
  • Phone: 619-661-6500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF99828
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number151418
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: