MEDICARE: MS. SARA INGRID VILLACORTA CNM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	538013	CA
2	367A00000X	Advanced Practice Midwife	1833	CA

General Provider Information

NPI Number	:	1568444982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SARA INGRID VILLACORTA CNM

Provider Business Mailing Address
First Line	:	2256 GLOVER PL
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-1129
Country	:	US
Telephone Number	:	619-955-3506
Fax Number	:

Provider Business Practice Location Address
First Line	:	2256 GLOVER PL
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-1129
Country	:	US
Telephone Number	:	619-955-3506
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2005
Last Update Date	:	09/26/2008

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