Healthcare Provider Details

I. General information

NPI: 1801830880
Provider Name (Legal Business Name): SANDRA LEE BAGWELL PHD, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 05/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21750 SACRAMENTO AVE
RED BLUFF CA
96080-7743
US

IV. Provider business mailing address

21750 SACRAMENTO AVE
RED BLUFF CA
96080-7743
US

V. Phone/Fax

Practice location:
  • Phone: 530-736-6072
  • Fax:
Mailing address:
  • Phone: 530-736-6072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number363069
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNPF10050
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: