Healthcare Provider Details

I. General information

NPI: 1730722851
Provider Name (Legal Business Name): CRISTINA HELENA VERGARA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2019
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 GREENCASTLE RD
TYRONE GA
30290-2936
US

IV. Provider business mailing address

190 GREENCASTLE RD
TYRONE GA
30290-2936
US

V. Phone/Fax

Practice location:
  • Phone: 949-680-9132
  • Fax:
Mailing address:
  • Phone: 949-680-9132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN268443
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN268443
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: