Provider Demographics
NPI:1205815248
Name:ALTAMIRA, JENNIFER (ACNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ALTAMIRA
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26800 CROWN VALLEY PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-8033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26800 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE 120
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691
Practice Address - Country:US
Practice Address - Phone:949-364-3388
Practice Address - Fax:949-364-5026
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15147363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGW186ZMedicare PIN
CAQ42033Medicare UPIN
CAWNP572378AMedicare PIN