Healthcare Provider Details

I. General information

NPI: 1326513441
Provider Name (Legal Business Name): SANDRA LYNN NIBBELINK AHEARN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 VISTA WAY STE B
OCEANSIDE CA
92056-3633
US

IV. Provider business mailing address

4225 EXECUTIVE SQ STE 450
LA JOLLA CA
92037-8411
US

V. Phone/Fax

Practice location:
  • Phone: 760-967-9900
  • Fax: 760-967-6769
Mailing address:
  • Phone: 858-810-8000
  • Fax: 858-268-1911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95007904
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: