Provider Demographics
NPI:1689096273
Name:VALENZUELA, SUSANA
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:
Last Name:VALENZUELA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 S IDYLLWILD AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-6844
Mailing Address - Country:US
Mailing Address - Phone:909-961-4389
Mailing Address - Fax:
Practice Address - Street 1:704 S IDYLLWILD AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-6844
Practice Address - Country:US
Practice Address - Phone:909-961-4389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN269391164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse