Provider Demographics
NPI:1740698950
Name:VILLANUEVA, JOHANNES GABERTAN (FNP)
Entity type:Individual
Prefix:
First Name:JOHANNES
Middle Name:GABERTAN
Last Name:VILLANUEVA
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 1:3131 BERGER AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4203
Mailing Address - Country:US
Mailing Address - Phone:760-715-4083
Mailing Address - Fax:
Practice Address - Street 1:602 CONCORD PL
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-1188
Practice Address - Country:US
Practice Address - Phone:760-715-4083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000993363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner