Basic Information
Provider Information | |||||||||
NPI: | 1215253885 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SANDOVAL | ||||||||
FirstName: | ROSE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-C, PMHNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 621 E LURAY ST | ||||||||
Address2: |   | ||||||||
City: | LONG BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 908071011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5625378287 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 21750 CENTER COURT DR. S | ||||||||
Address2: | SUITE 650 | ||||||||
City: | CERRITOS | ||||||||
State: | CA | ||||||||
PostalCode: | 90703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3236288671 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2010 | ||||||||
LastUpdateDate: | 10/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 713753 | CA | N |   | Nursing Service Providers | Registered Nurse |   | 363LP0808X | 19256 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.