Provider Demographics
NPI:1518589944
Name:CALLUENG, JENNIFER VIDA DIEGO (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER VIDA
Middle Name:DIEGO
Last Name:CALLUENG
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 1:14051 RAMONA PKWY
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-4114
Mailing Address - Country:US
Mailing Address - Phone:626-960-3753
Mailing Address - Fax:626-962-9866
Practice Address - Street 1:14051 RAMONA PKWY
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-4114
Practice Address - Country:US
Practice Address - Phone:626-960-3753
Practice Address - Fax:626-962-9866
Is Sole Proprietor?:No
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014306363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily