Healthcare Provider Details

I. General information

NPI: 1487363677
Provider Name (Legal Business Name): CHERRY PANDONGIT LIWAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2022
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5202 UNIVERSITY AVE
SAN DIEGO CA
92105-2268
US

IV. Provider business mailing address

1202 E 6TH ST APT 2
NATIONAL CITY CA
91950-2555
US

V. Phone/Fax

Practice location:
  • Phone: 619-229-5430
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number95111084
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: