Provider Demographics
NPI:1477316321
Name:IBARRA, ASHLEY GISELLE
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:GISELLE
Last Name:IBARRA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 LILLEAN CT
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-1880
Mailing Address - Country:US
Mailing Address - Phone:707-654-7421
Mailing Address - Fax:
Practice Address - Street 1:17862 17TH ST STE 107
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2170
Practice Address - Country:US
Practice Address - Phone:714-661-5390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-02
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty