Provider Demographics
NPI:1790711935
Name:HUBBARD, IONELA O (LAC, DOM, IFMCP)
Entity type:Individual
Prefix:
First Name:IONELA
Middle Name:O
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:LAC, DOM, IFMCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 PLYMOUTH
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-2642
Mailing Address - Country:US
Mailing Address - Phone:909-478-0600
Mailing Address - Fax:909-478-0618
Practice Address - Street 1:12341 NEWPORT AVE STE A200
Practice Address - Street 2:
Practice Address - City:NORTH TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92705-8202
Practice Address - Country:US
Practice Address - Phone:949-726-0707
Practice Address - Fax:949-258-8726
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC4756171100000X, 133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1790711935OtherCMV
CAAC0047560Medicaid