1891514824 NPI number — MRS. ELLIS PETRONELLA VAN DEN BOOGAARD MS ED., MA

Table of content: MRS. ELLIS PETRONELLA VAN DEN BOOGAARD MS ED., MA (NPI 1891514824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891514824 NPI number — MRS. ELLIS PETRONELLA VAN DEN BOOGAARD MS ED., MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN DEN BOOGAARD
Provider First Name:
ELLIS
Provider Middle Name:
PETRONELLA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS ED., MA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891514824
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
251 AIRPORT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCEANSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92058-1201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-072-1170
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5335 CALLE VIS
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92109-1920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-882-7860
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/07/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106S00000X , with the licence number:  19-109521 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106S00000X , with the licence number: 23-294299 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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