Healthcare Provider Details

I. General information

NPI: 1790056380
Provider Name (Legal Business Name): EMMACULATE MMBOGA FIELDS APRN-CNP FAMILY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2012
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR
SAN DIEGO CA
92103-9000
US

IV. Provider business mailing address

FILE 57326
LOS ANGELES CA
90074-7326
US

V. Phone/Fax

Practice location:
  • Phone: 800-926-8273
  • Fax: 888-539-8781
Mailing address:
  • Phone: 800-926-8273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95023802
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95023802
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0089445
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: