Healthcare Provider Details

I. General information

NPI: 1023790128
Provider Name (Legal Business Name): ERIKA JEANNE PROVENCE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31625 DE PORTOLA RD STE 101
TEMECULA CA
92592-2770
US

IV. Provider business mailing address

31625 DE PORTOLA RD STE 101
TEMECULA CA
92592-2770
US

V. Phone/Fax

Practice location:
  • Phone: 951-501-4200
  • Fax:
Mailing address:
  • Phone: 951-501-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95025012
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number622055
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: