Healthcare Provider Details

I. General information

NPI: 1720121353
Provider Name (Legal Business Name): SANDRA G ULLOA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 POMONA BLVD
LOS ANGELES CA
90022-1716
US

IV. Provider business mailing address

4727 DOZIER AVE
LOS ANGELES CA
90022-1320
US

V. Phone/Fax

Practice location:
  • Phone: 323-728-0411
  • Fax:
Mailing address:
  • Phone: 323-262-1122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number678160
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: