Basic Information
| Provider Information | |||||||||
| NPI: | 1356980213 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERMUDEZ | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 800 FERRARI LN SUITE 100 | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917645031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094842848 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 FERRARI LN SUITE 100 | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917645031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094842848 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2019 | ||||||||
| LastUpdateDate: | 12/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/24/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | F3243412 | CA | Y |
No ID Information.