Provider Demographics
NPI:1285469395
Name:MONTALVO, MONICA
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:MONTALVO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15497 W SAND ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-2910
Mailing Address - Country:US
Mailing Address - Phone:442-327-9311
Mailing Address - Fax:
Practice Address - Street 1:15497 W SAND ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2910
Practice Address - Country:US
Practice Address - Phone:442-327-9311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC15BF-07-08-E-24-019172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty