Healthcare Provider Details

I. General information

NPI: 1255982880
Provider Name (Legal Business Name): SARA Y TIZAZU LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1664 BROADWAY
EL CAJON CA
92021-5201
US

IV. Provider business mailing address

1664 BROADWAY
EL CAJON CA
92021-5201
US

V. Phone/Fax

Practice location:
  • Phone: 619-579-8685
  • Fax:
Mailing address:
  • Phone: 619-579-8685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number195892
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: