Provider Demographics
NPI:1225549439
Name:PONCE, MAYRA SHIRLEY (FNP)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:SHIRLEY
Last Name:PONCE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MAYRA
Other - Middle Name:SHIRLEY
Other - Last Name:PONCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NF
Mailing Address - Street 1:11261 RATLIFFE ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-2779
Mailing Address - Country:US
Mailing Address - Phone:562-333-5831
Mailing Address - Fax:
Practice Address - Street 1:11261 RATLIFFE ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-2779
Practice Address - Country:US
Practice Address - Phone:562-333-5831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-14
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9536305163W00000X
CA95253221163W00000X
CA17-419246ZC0007X
FLAPRN11023540363LF0000X
CANP95026873363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered Nurse
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant