Provider Demographics
NPI:1689179491
Name:PONCE DE LEON, BERNICE PUACHE (DO)
Entity Type:Individual
Prefix:
First Name:BERNICE
Middle Name:PUACHE
Last Name:PONCE DE LEON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5940 S RAINBOW BLVD STE 736
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-2506
Mailing Address - Country:US
Mailing Address - Phone:626-559-2190
Mailing Address - Fax:
Practice Address - Street 1:5940 S RAINBOW BLVD STE 736
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-2506
Practice Address - Country:US
Practice Address - Phone:626-559-2190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A191572084P0800X
390200000X
NVDO35592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program