Provider Demographics
NPI:1376208975
Name:ADVINCULA, GRACIELLE MAE EJANDA (NP)
Entity Type:Individual
Prefix:
First Name:GRACIELLE MAE
Middle Name:EJANDA
Last Name:ADVINCULA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2177 DIAMONDBACK CT UNIT 21
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-2900
Mailing Address - Country:US
Mailing Address - Phone:909-231-4348
Mailing Address - Fax:
Practice Address - Street 1:1306 BROADWAY
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5810
Practice Address - Country:US
Practice Address - Phone:619-551-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA95018873363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95018873OtherNP STATE LICENSE