Provider Demographics
NPI:1255014965
Name:PORTILLO, VERONICA JIMENEZ (FNP-C)
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:JIMENEZ
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10328 BALSAM AVE
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-2814
Mailing Address - Country:US
Mailing Address - Phone:760-680-9604
Mailing Address - Fax:
Practice Address - Street 1:17259 JASMINE ST STE B
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7787
Practice Address - Country:US
Practice Address - Phone:760-241-4929
Practice Address - Fax:760-241-5950
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95026451363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily