Provider Demographics
NPI:1902479728
Name:GUADALUPE MENJIVAR, ILIANA VANESSA (RN)
Entity Type:Individual
Prefix:
First Name:ILIANA
Middle Name:VANESSA
Last Name:GUADALUPE MENJIVAR
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14721 ANTILLES DR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-2949
Mailing Address - Country:US
Mailing Address - Phone:714-360-9940
Mailing Address - Fax:
Practice Address - Street 1:14721 ANTILLES DR
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-2949
Practice Address - Country:US
Practice Address - Phone:714-360-9940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2351288363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics