Healthcare Provider Details

I. General information

NPI: 1609457753
Provider Name (Legal Business Name): KANDAVIN SUMILAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2195 CLUB CENTER DR STE A
SAN BERNARDINO CA
92408-4162
US

IV. Provider business mailing address

PO BOX 10069
SAN BERNARDINO CA
92423-0069
US

V. Phone/Fax

Practice location:
  • Phone: 909-654-2119
  • Fax:
Mailing address:
  • Phone: 909-335-4188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95022634
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: