Provider Demographics
NPI:1063975308
Name:PONCE, MACAYLA JOSEPHINE
Entity type:Individual
Prefix:
First Name:MACAYLA
Middle Name:JOSEPHINE
Last Name:PONCE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-4401
Mailing Address - Country:US
Mailing Address - Phone:909-593-3511
Mailing Address - Fax:
Practice Address - Street 1:1950 3RD ST
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-4401
Practice Address - Country:US
Practice Address - Phone:909-593-3511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician