Provider Demographics
NPI:1568174795
Name:RONQUILLO, MARY ROSE (FNP)
Entity Type:Individual
Prefix:
First Name:MARY ROSE
Middle Name:
Last Name:RONQUILLO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13651 WILLARD STREET
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402
Mailing Address - Country:US
Mailing Address - Phone:818-645-4510
Mailing Address - Fax:
Practice Address - Street 1:13651 WILLARD STREET
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402
Practice Address - Country:US
Practice Address - Phone:818-645-4510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95026686363LF0000X
CA796899163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily