Basic Information
| Provider Information | |||||||||
| NPI: | 1134563695 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IGNACIO | ||||||||
| FirstName: | CARMELA | ||||||||
| MiddleName: | VILLARIN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 FAIR OAKS AVE STE 270 | ||||||||
| Address2: | |||||||||
| City: | SOUTH PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910305801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263462455 | ||||||||
| FaxNumber: | 6266393005 | ||||||||
| Practice Location | |||||||||
| Address1: | 24853 ALESSANDRO BLVD | ||||||||
| Address2: | #4 | ||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925536102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515718518 | ||||||||
| FaxNumber: | 8777789427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2013 | ||||||||
| LastUpdateDate: | 04/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP22782 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 22782 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | EFF.6/4/13-ADELANTO | 05 | CA | MEDICAID | EFF.6/3/13-RIALT,FON | 05 | CA | MEDICAID | EFF.6/3/13-S&N.RIVER | 05 | CA | MEDICAID | EFF.6/3/13-MORENOVAL | 05 | CA | MEDICAID | P01282955/DU4034 | 01 | CA | RAILROAD MEDICARE | OTHER | EFF.6/4/13-SB,ONTARI | 05 | CA | MEDICAID |