Healthcare Provider Details

I. General information

NPI: 1609299791
Provider Name (Legal Business Name): POLLY WASHBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2014
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 W HIGHLAND AVE
SAN BERNARDINO CA
92411-1235
US

IV. Provider business mailing address

1535 W HIGHLAND AVE
SAN BERNARDINO CA
92411-1235
US

V. Phone/Fax

Practice location:
  • Phone: 909-880-6839
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number21467
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number334754
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: