Healthcare Provider Details

I. General information

NPI: 1659036630
Provider Name (Legal Business Name): NANCY JANET REGIN SUDRC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 HOTEL CIR N
SAN DIEGO CA
92108-2807
US

IV. Provider business mailing address

655 MYRA AVE
CHULA VISTA CA
91910-6229
US

V. Phone/Fax

Practice location:
  • Phone: 619-961-2120
  • Fax:
Mailing address:
  • Phone: 619-869-3721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: