Healthcare Provider Details

I. General information

NPI: 1255204517
Provider Name (Legal Business Name): DAVID SANDOVAL LLANEZA RN BSN PHN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2025
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SAN LEANDRO BLVD FL 3
SAN LEANDRO CA
94577-1595
US

IV. Provider business mailing address

1100 SAN LEANDRO BLVD FL 3
SAN LEANDRO CA
94577-1595
US

V. Phone/Fax

Practice location:
  • Phone: 510-667-3096
  • Fax:
Mailing address:
  • Phone: 510-667-3096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number561631
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95086159
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: