Provider Demographics
NPI:1518674605
Name:EXCONDE-MERCADO, CATHLEEN VANESSA GUTIERREZ (RN, NP)
Entity Type:Individual
Prefix:
First Name:CATHLEEN VANESSA
Middle Name:GUTIERREZ
Last Name:EXCONDE-MERCADO
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:CATHLEEN VANESSA
Other - Middle Name:GUTIERREZ
Other - Last Name:EXCONDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4798 S SCOTT WAY
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-7365
Mailing Address - Country:US
Mailing Address - Phone:415-629-0525
Mailing Address - Fax:
Practice Address - Street 1:1620 E 2ND ST STE N
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-3172
Practice Address - Country:US
Practice Address - Phone:951-845-6500
Practice Address - Fax:866-856-0338
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF10220152363LF0000X
CA95023464363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily