MEDICARE: MRS. CONCHITA ESTHER PORTILLA NURSE PRACTITIONER P

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	402401	CA

General Provider Information

NPI Number	:	1649232075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CONCHITA ESTHER PORTILLA NURSE PRACTITIONER P

Provider Business Mailing Address
First Line	:	400 N. PEPPER AVE.
Second Line	:	PEDIATRICS ADMINISTRATION
City	:	COLTON
State	:	CA
Zip	:	92324-1819
Country	:	US
Telephone Number	:	909-498-6277
Fax Number	:	909-580-3235

Provider Business Practice Location Address
First Line	:	400 N PEPPER AVE
Second Line	:	PEDIATRICS ADMINISTRATION
City	:	COLTON
State	:	CA
Zip	:	92324-1819
Country	:	US
Telephone Number	:	909-498-6277
Fax Number	:	909-580-3235

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2006
Last Update Date	:	12/22/2014

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