Provider Demographics
NPI:1780141317
Name:CORONADO, ITZEL (LAC)
Entity type:Individual
Prefix:
First Name:ITZEL
Middle Name:
Last Name:CORONADO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1534 LOCHNER DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95127-4765
Mailing Address - Country:US
Mailing Address - Phone:408-413-8315
Mailing Address - Fax:
Practice Address - Street 1:21040 HOMESTEAD RD STE 102
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-0238
Practice Address - Country:US
Practice Address - Phone:408-413-8315
Practice Address - Fax:408-743-5445
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-01
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18400171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist