Healthcare Provider Details

I. General information

NPI: 1619890274
Provider Name (Legal Business Name): DAISY JASMINE CERVANIA HUERTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3467 EDGEWATER PL
VALLEJO CA
94591-8398
US

IV. Provider business mailing address

3467 EDGEWATER PL
VALLEJO CA
94591-8398
US

V. Phone/Fax

Practice location:
  • Phone: 707-732-8105
  • Fax: 707-667-0010
Mailing address:
  • Phone: 707-732-8105
  • Fax: 707-667-0010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: