Healthcare Provider Details

I. General information

NPI: 1326740036
Provider Name (Legal Business Name): SONIA MARIE BALLESTEROS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 03/20/2023
Certification Date: 03/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 N COLLEGE WAY
CLAREMONT CA
91711-3944
US

IV. Provider business mailing address

311 E BENNETT AVE
GLENDORA CA
91741-2646
US

V. Phone/Fax

Practice location:
  • Phone: 909-621-8222
  • Fax:
Mailing address:
  • Phone: 626-590-6776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1400X
TaxonomyCollege Health Registered Nurse
License Number686455
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: