Provider Demographics
NPI:1972260685
Name:IBARRA, YESENIA
Entity type:Individual
Prefix:
First Name:YESENIA
Middle Name:
Last Name:IBARRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:YESENIA
Other - Middle Name:GUADALUPE
Other - Last Name:IBARRA CARVAJAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:220 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3827
Mailing Address - Country:US
Mailing Address - Phone:310-640-2715
Mailing Address - Fax:310-640-0804
Practice Address - Street 1:220 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3827
Practice Address - Country:US
Practice Address - Phone:424-391-9955
Practice Address - Fax:310-640-0804
Is Sole Proprietor?:No
Enumeration Date:2021-11-17
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374700000X
CA124820183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
No374700000XNursing Service Related ProvidersTechnician