Healthcare Provider Details

I. General information

NPI: 1609204155
Provider Name (Legal Business Name): VANESSA TELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2013
Last Update Date: 10/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 W GARVEY AVE N
WEST COVINA CA
91790-2138
US

IV. Provider business mailing address

15196 MORENO BEACH DR #1122
MORENO VALLEY CA
92555-5513
US

V. Phone/Fax

Practice location:
  • Phone: 626-962-6061
  • Fax:
Mailing address:
  • Phone: 951-259-2558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number273850
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: