Provider Demographics
NPI:1477010510
Name:FONDEVILLA, AFRIELLE (NP)
Entity Type:Individual
Prefix:
First Name:AFRIELLE
Middle Name:
Last Name:FONDEVILLA
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 1:1900 W GARVEY AVE S STE 166
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2653
Mailing Address - Country:US
Mailing Address - Phone:626-960-1402
Mailing Address - Fax:
Practice Address - Street 1:1900 W GARVEY AVE S STE 166
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2653
Practice Address - Country:US
Practice Address - Phone:626-960-1402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010453363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health