Healthcare Provider Details

I. General information

NPI: 1679255327
Provider Name (Legal Business Name): SANDRA HLAVAC FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31625 DE PORTOLA RD STE 101
TEMECULA CA
92592-2770
US

IV. Provider business mailing address

31625 DE PORTOLA RD STE 101
TEMECULA CA
92592-2770
US

V. Phone/Fax

Practice location:
  • Phone: 951-501-4200
  • Fax:
Mailing address:
  • Phone: 951-501-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95026415
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: