Provider Demographics
NPI:1710616735
Name:AGUELO, AMABELLE JUNE BLAZADO
Entity Type:Individual
Prefix:
First Name:AMABELLE JUNE
Middle Name:BLAZADO
Last Name:AGUELO
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 1:7159 MYRTLE PL
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-5706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 W TOWN AND COUNTRY RD STE 1300
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4654
Practice Address - Country:US
Practice Address - Phone:855-434-7763
Practice Address - Fax:949-281-5550
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95021106363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily