Provider Demographics
NPI:1043773369
Name:PONGO, ANDREA (LM, CPM)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:
Last Name:PONGO
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 COCHRAN ST STE 205
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-2500
Mailing Address - Country:US
Mailing Address - Phone:613-478-3426
Mailing Address - Fax:661-481-7277
Practice Address - Street 1:3355 COCHRAN ST STE 205
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-2500
Practice Address - Country:US
Practice Address - Phone:661-347-8342
Practice Address - Fax:661-481-7277
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA567176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife