Healthcare Provider Details

I. General information

NPI: 1881192417
Provider Name (Legal Business Name): RONALDO CHINO PETALLO TANEDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 4TH AVE STE 300
SAN DIEGO CA
92103-3119
US

IV. Provider business mailing address

3930 4TH AVE STE 300
SAN DIEGO CA
92103-3119
US

V. Phone/Fax

Practice location:
  • Phone: 619-320-8711
  • Fax: 619-393-0818
Mailing address:
  • Phone: 619-320-8711
  • Fax: 619-393-0818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95032892
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number739150
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: