Healthcare Provider Details

I. General information

NPI: 1023859600
Provider Name (Legal Business Name): SANDRA MABEL BUENRROSTRO REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 E LIVE OAK AVE
ARCADIA CA
91006-5617
US

IV. Provider business mailing address

12911 DEL SUR ST
SAN FERNANDO CA
91340-1519
US

V. Phone/Fax

Practice location:
  • Phone: 626-254-1400
  • Fax:
Mailing address:
  • Phone: 818-403-0195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number720066
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: