Healthcare Provider Details

I. General information

NPI: 1841774817
Provider Name (Legal Business Name): BLESSY SABU AGAC-NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 03/22/2025
Certification Date: 03/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 BENTON ST
LOMA LINDA CA
92357-3312
US

IV. Provider business mailing address

14539 ALDER DR
EASTVALE CA
92880-9616
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax:
Mailing address:
  • Phone: 714-329-2868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberNP95009183
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberNP95009183
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: