Provider Demographics
NPI:1760047799
Name:JERONIMO SOSA, ANA CARMEN
Entity Type:Individual
Prefix:
First Name:ANA
Middle Name:CARMEN
Last Name:JERONIMO SOSA
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 1:2000 TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91733-3543
Mailing Address - Country:US
Mailing Address - Phone:562-332-3641
Mailing Address - Fax:562-334-3518
Practice Address - Street 1:2000 TYLER AVE
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91733-3543
Practice Address - Country:US
Practice Address - Phone:562-332-3641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA171M00000XMedicaid