Healthcare Provider Details

I. General information

NPI: 1821921065
Provider Name (Legal Business Name): ILONA IGNATJEVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2026
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 N SAN MATEO DR
SAN MATEO CA
94401-2418
US

IV. Provider business mailing address

345 RODGERS ST
VALLEJO CA
94590-3070
US

V. Phone/Fax

Practice location:
  • Phone: 707-997-8029
  • Fax:
Mailing address:
  • Phone: 707-997-8029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number30000745L
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: