Healthcare Provider Details

I. General information

NPI: 1972148377
Provider Name (Legal Business Name): MRS. VICTORIA BONIFACIO YI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2019
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 N MOUNTAIN AVE STE 103
UPLAND CA
91786-5183
US

IV. Provider business mailing address

3345 OAKHURST AVE
LOS ANGELES CA
90034-2827
US

V. Phone/Fax

Practice location:
  • Phone: 805-719-3700
  • Fax: 805-413-9099
Mailing address:
  • Phone: 909-996-0678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95012826
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: