Healthcare Provider Details

I. General information

NPI: 1164038022
Provider Name (Legal Business Name): CHRISTINE ANTOINETTE VERGARA RN, PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINE ANTOINETTE RUIZ LVN

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W 5TH ST
SANTA ANA CA
92701-4599
US

IV. Provider business mailing address

405 W 5TH ST
SANTA ANA CA
92701-4599
US

V. Phone/Fax

Practice location:
  • Phone: 714-461-8379
  • Fax:
Mailing address:
  • Phone: 714-834-4144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95028068
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95189049
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: