Healthcare Provider Details

I. General information

NPI: 1154981355
Provider Name (Legal Business Name): VIVIANE SANADA NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ROSECRANS AVE STE 3230
EL SEGUNDO CA
90245-4749
US

IV. Provider business mailing address

7720 FAY AVE
LA JOLLA CA
92037
US

V. Phone/Fax

Practice location:
  • Phone: 323-628-8671
  • Fax:
Mailing address:
  • Phone: 858-454-2700
  • Fax: 858-454-2782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95011080
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: