Healthcare Provider Details

I. General information

NPI: 1215359468
Provider Name (Legal Business Name): SALLY MAHMOUD RN, BSN, PUBLIC HEAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2014
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4065 COUNTY CIRCLE DRIVE COUNTY OF RIVERSIDE DEPARTMENT OF PUBLIC HEALTH PHN/MCA
RIVERSIDE CA
92503
US

IV. Provider business mailing address

4065 COUNTY CIRCLE DRIVE COUNTY OF RIVERSIDE DEPARTMENT OF PUBLIC HEALTH PHN/MCA
RIVERSIDE CA
92503
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-5438
  • Fax:
Mailing address:
  • Phone: 951-358-5438
  • Fax: 951-358-5019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number542956RN
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: