Provider Demographics
NPI:1457823841
Name:MONTEFALCON, CONNIE AGABIN (NP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:AGABIN
Last Name:MONTEFALCON
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 1:45617 CLASSIC WAY
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-6032
Mailing Address - Country:US
Mailing Address - Phone:619-246-9539
Mailing Address - Fax:
Practice Address - Street 1:45617 CLASSIC WAY
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-6032
Practice Address - Country:US
Practice Address - Phone:619-246-9539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-22
Last Update Date:2018-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010651363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology