Healthcare Provider Details

I. General information

NPI: 1124763164
Provider Name (Legal Business Name): JAY SANTILLANA LARDIZABAL MSN, APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 05/04/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6595 CANTATA DR
EASTVALE CA
92880-4534
US

IV. Provider business mailing address

6595 CANTATA DR
EASTVALE CA
92880-4534
US

V. Phone/Fax

Practice location:
  • Phone: 951-987-1133
  • Fax:
Mailing address:
  • Phone: 951-987-1133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF04220387
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: