Basic Information
| Provider Information | |||||||||
| NPI: | 1437588076 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VILLANUEVA | ||||||||
| FirstName: | THEA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13520 PARK CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | BALDWIN PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917062265 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 12900 PARK PLAZA DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | CERRITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907039329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666463553 | ||||||||
| FaxNumber: | 5626223058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2013 | ||||||||
| LastUpdateDate: | 01/10/2014 | ||||||||
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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 | 363LG0600X | 23502 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.