Provider Demographics
NPI:1841998341
Name:VILLARREAL-ANTILLON, SOPHIA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:VILLARREAL-ANTILLON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 ROSEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-1766
Mailing Address - Country:US
Mailing Address - Phone:951-333-0073
Mailing Address - Fax:
Practice Address - Street 1:1731 E 120TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3051
Practice Address - Country:US
Practice Address - Phone:951-333-0073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95024444363LF0000X
CA95055738163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily