Provider Demographics
NPI:1972846756
Name:VENTOCILLA, MARIELA CELESTE
Entity Type:Individual
Prefix:
First Name:MARIELA
Middle Name:CELESTE
Last Name:VENTOCILLA
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 1:3101 UPSHUR AVE APT C
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277-9482
Mailing Address - Country:US
Mailing Address - Phone:408-458-0132
Mailing Address - Fax:
Practice Address - Street 1:1145 STURGIS ROAD
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277
Practice Address - Country:US
Practice Address - Phone:916-734-2356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-31
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X, 390200000X
VA010127041207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010127041OtherLISCENCE NUMBER