Healthcare Provider Details

I. General information

NPI: 1215456298
Provider Name (Legal Business Name): RUSSE ELLA MUNAR LAXA FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS RUSSE ELLA MUNAR IGNACIO

II. Dates (important events)

Enumeration Date: 09/11/2017
Last Update Date: 09/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 CEDAR RD
VISTA CA
92083-5102
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD # 4S-205
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 760-806-5400
  • Fax:
Mailing address:
  • Phone: 760-806-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95005842
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: