Provider Demographics
NPI:1649232075
Name:PORTILLA, CONCHITA ESTHER (NURSE PRACTITIONER P)
Entity Type:Individual
Prefix:MRS
First Name:CONCHITA
Middle Name:ESTHER
Last Name:PORTILLA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER P
Other - Prefix:
Other - First Name:CONCHITA
Other - Middle Name:ESTHER
Other - Last Name:LEON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NURSE PRACTITIONER P
Mailing Address - Street 1:400 N. PEPPER AVE.
Mailing Address - Street 2:PEDIATRICS ADMINISTRATION
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-1819
Mailing Address - Country:US
Mailing Address - Phone:909-498-6277
Mailing Address - Fax:909-580-3235
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:PEDIATRICS ADMINISTRATION
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1819
Practice Address - Country:US
Practice Address - Phone:909-498-6277
Practice Address - Fax:909-580-3235
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA402401363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics