Provider Demographics
NPI:1902017064
Name:PUNZALAN, NIMFA REALEZA (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:NIMFA
Middle Name:REALEZA
Last Name:PUNZALAN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3313 EL PINOLE WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-7208
Mailing Address - Country:US
Mailing Address - Phone:707-425-2202
Mailing Address - Fax:707-425-6060
Practice Address - Street 1:3313 EL PINOLE WAY
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-7208
Practice Address - Country:US
Practice Address - Phone:707-425-2202
Practice Address - Fax:707-425-6060
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC61010FOtherPROVIDER IDENTIFICATION #