Healthcare Provider Details

I. General information

NPI: 1043773369
Provider Name (Legal Business Name): ANDREA PONGO LM, CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 COCHRAN ST STE 205
SIMI VALLEY CA
93063-2500
US

IV. Provider business mailing address

3355 COCHRAN ST STE 205
SIMI VALLEY CA
93063-2500
US

V. Phone/Fax

Practice location:
  • Phone: 661-347-8342
  • Fax: 661-481-7277
Mailing address:
  • Phone: 613-478-3426
  • Fax: 661-481-7277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number567
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: