Provider Demographics
NPI:1437588076
Name:VILLANUEVA, THEA (NP)
Entity Type:Individual
Prefix:
First Name:THEA
Middle Name:
Last Name:VILLANUEVA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13520 PARK CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-2265
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12900 PARK PLAZA DR STE 150
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-9329
Practice Address - Country:US
Practice Address - Phone:866-646-3553
Practice Address - Fax:562-622-3058
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23502363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology