Healthcare Provider Details

I. General information

NPI: 1841460797
Provider Name (Legal Business Name): FLORENCIA O SISTERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 ROSECRANS ST
SAN DIEGO CA
92110
US

IV. Provider business mailing address

5739 BAJA DR
SAN DIEGO CA
92115-2326
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-8691
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95009388
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number731387
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: