Healthcare Provider Details

I. General information

NPI: 1366615791
Provider Name (Legal Business Name): SANDRA IMADE ODIASE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANDRA IMADE ODIASE

II. Dates (important events)

Enumeration Date: 04/07/2008
Last Update Date: 08/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3946 NORWOOD AVE
SACRAMENTO CA
95838-3300
US

IV. Provider business mailing address

200 OCEANGATE SUITE 100
LONG BEACH CA
90802-4317
US

V. Phone/Fax

Practice location:
  • Phone: 916-564-0521
  • Fax: 877-860-2907
Mailing address:
  • Phone: 562-499-6191
  • Fax: 877-860-5422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17711
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number17711
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: