Provider Demographics
NPI:1679806145
Name:CUSTODIO, ANNABELLE ALONZO (FNP)
Entity Type:Individual
Prefix:MRS
First Name:ANNABELLE
Middle Name:ALONZO
Last Name:CUSTODIO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9041 MAGNOLIA AVE SUITE 206
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3956
Mailing Address - Country:US
Mailing Address - Phone:951-354-0676
Mailing Address - Fax:951-354-5786
Practice Address - Street 1:9041 MAGNOLIA AVE STE 206
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3956
Practice Address - Country:US
Practice Address - Phone:951-354-0676
Practice Address - Fax:951-354-5786
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18332363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily