Provider Demographics
NPI:1134563695
Name:IGNACIO, CARMELA VILLARIN (NP)
Entity type:Individual
Prefix:
First Name:CARMELA
Middle Name:VILLARIN
Last Name:IGNACIO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 FAIR OAKS AVE STE 270
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-5801
Mailing Address - Country:US
Mailing Address - Phone:626-346-2455
Mailing Address - Fax:626-639-3005
Practice Address - Street 1:24853 ALESSANDRO BLVD
Practice Address - Street 2:#4
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-6102
Practice Address - Country:US
Practice Address - Phone:951-571-8518
Practice Address - Fax:877-778-9427
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-26
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP22782363L00000X
CA22782363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEFF.6/4/13-ADELANTOMedicaid
CAEFF.6/3/13-RIALT,FONMedicaid
CAEFF.6/3/13-S&N.RIVERMedicaid
CAEFF.6/3/13-MORENOVALMedicaid
CAP01282955/DU4034OtherRAILROAD MEDICARE
CAEFF.6/4/13-SB,ONTARIMedicaid
CAEFF.6/3/13-S&N.RIVERMedicaid