Healthcare Provider Details

I. General information

NPI: 1184102758
Provider Name (Legal Business Name): MARIA COREENA VENGCO VELASCO MS, AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2018
Last Update Date: 03/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVE BLDG 1, RM 101
SAN FRANCISCO CA
94110
US

IV. Provider business mailing address

1001 POTRERO AVE BLDG 1, RM 101
SAN FRANCISCO CA
94110
US

V. Phone/Fax

Practice location:
  • Phone: 415-206-8000
  • Fax:
Mailing address:
  • Phone: 415-206-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95009736
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: