Healthcare Provider Details

I. General information

NPI: 1902451263
Provider Name (Legal Business Name): KIMBERLY M. SANDBERG, RN, CRNA, A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2019
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 EXECUTIVE DR STE 108
SAN DIEGO CA
92121-3022
US

IV. Provider business mailing address

2833 ASPEN GLEN CT
CHULA VISTA CA
91914-2523
US

V. Phone/Fax

Practice location:
  • Phone: 619-333-3515
  • Fax: 833-974-2067
Mailing address:
  • Phone: 619-944-2760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: KIM SANDBERG
Title or Position: OWNER
Credential: CRNA
Phone: 619-944-2760