Provider Demographics
NPI:1316314693
Name:VRECA-PONNEQUIN, VIDA (FNP-BC)
Entity type:Individual
Prefix:
First Name:VIDA
Middle Name:
Last Name:VRECA-PONNEQUIN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 MERCY AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340
Mailing Address - Country:US
Mailing Address - Phone:209-564-3700
Mailing Address - Fax:209-564-3725
Practice Address - Street 1:315 MERCY AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340
Practice Address - Country:US
Practice Address - Phone:209-564-3700
Practice Address - Fax:209-564-3725
Is Sole Proprietor?:No
Enumeration Date:2015-08-21
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002571363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily