Healthcare Provider Details

I. General information

NPI: 1912139114
Provider Name (Legal Business Name): RUPINDERJIT KAUR SAMRA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RUPINDERJIT K SAMRA NURSE PRACTITIONER

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 V ST STE G400
SACRAMENTO CA
95817-1460
US

IV. Provider business mailing address

4150 V ST STE G400
SACRAMENTO CA
95817-1460
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-8464
  • Fax: 916-734-7953
Mailing address:
  • Phone: 916-734-8464
  • Fax: 916-734-7953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number17660
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number3026
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number629802
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: