Provider Demographics
NPI:1649832726
Name:PONSE, MICHELLE E
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:E
Last Name:PONSE
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 1:201 D ST STE R
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-5952
Mailing Address - Country:US
Mailing Address - Phone:530-702-0088
Mailing Address - Fax:
Practice Address - Street 1:201 D ST STE R
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-5952
Practice Address - Country:US
Practice Address - Phone:530-702-0088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist