Provider Demographics
NPI:1063867380
Name:PENAFLOR, JESSICA SUSANA RIDAO (AGNP-C)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:SUSANA RIDAO
Last Name:PENAFLOR
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:MRS
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:RIDAO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1000 W CARSON ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:310-222-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-25
Last Update Date:2018-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004141207R00000X, 363LA2200X, 363LP2300X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care