Provider Demographics
NPI:1023790128
Name:PROVENCE, ERIKA JEANNE (FNP)
Entity type:Individual
Prefix:
First Name:ERIKA
Middle Name:JEANNE
Last Name:PROVENCE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31625 DE PORTOLA RD STE 101
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-2770
Mailing Address - Country:US
Mailing Address - Phone:951-501-4200
Mailing Address - Fax:
Practice Address - Street 1:31625 DE PORTOLA RD STE 101
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-2770
Practice Address - Country:US
Practice Address - Phone:951-501-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA622055163W00000X
CA95025012363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse