Healthcare Provider Details

I. General information

NPI: 1144901349
Provider Name (Legal Business Name): AMANDA DORA BLANCO CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST
LOMA LINDA CA
92350-1716
US

IV. Provider business mailing address

11234 ANDERSON ST
LOMA LINDA CA
92350-1716
US

V. Phone/Fax

Practice location:
  • Phone: 626-905-1569
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95002484
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95065011
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95065011
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: