Healthcare Provider Details

I. General information

NPI: 1750706263
Provider Name (Legal Business Name): SASHA BALLEZA CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2014
Last Update Date: 12/31/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3605 VISTA WAY STE 130
OCEANSIDE CA
92056-4565
US

IV. Provider business mailing address

3605 VISTA WAY STE 130
OCEANSIDE CA
92056-4565
US

V. Phone/Fax

Practice location:
  • Phone: 760-547-1010
  • Fax: 760-547-1011
Mailing address:
  • Phone: 760-547-1010
  • Fax: 760-547-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2284708
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number845876
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95001230
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: