Provider Demographics
NPI:1366098170
Name:OMANA, IVONNE ANDREA
Entity type:Individual
Prefix:
First Name:IVONNE
Middle Name:ANDREA
Last Name:OMANA
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:PO BOX 4773
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-4773
Mailing Address - Country:US
Mailing Address - Phone:407-241-9489
Mailing Address - Fax:
Practice Address - Street 1:790 E BONITA AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1906
Practice Address - Country:US
Practice Address - Phone:909-625-7207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-16
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty