Healthcare Provider Details

I. General information

NPI: 1881678233
Provider Name (Legal Business Name): RUBY VILLAVISENCIO MSN, CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 E DYER RD STE 145
SANTA ANA CA
92705-5694
US

IV. Provider business mailing address

32 CELESTINE CIR
LADERA RANCH CA
92694-0829
US

V. Phone/Fax

Practice location:
  • Phone: 949-449-1285
  • Fax:
Mailing address:
  • Phone: 949-682-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number10927
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number508591
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number10927
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: