Healthcare Provider Details

I. General information

NPI: 1639058811
Provider Name (Legal Business Name): SAMANTHA PONS NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2195 CLUB CENTER DR STE A
SAN BERNARDINO CA
92408-4162
US

IV. Provider business mailing address

14975 AVENIDA ANITA
CHINO HILLS CA
91709-6210
US

V. Phone/Fax

Practice location:
  • Phone: 909-654-2199
  • Fax:
Mailing address:
  • Phone: 626-378-1523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95035079
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: