=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841584778
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHERYL LEE O. DE LA CRUZ NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2011
-----------------------------------------------------
Last Update Date | 06/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1850 S WATERMAN AVE STE D
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92408-2852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-891-1164
-----------------------------------------------------
Fax | 909-383-6689
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 330 W RAMSEY ST
-----------------------------------------------------
City | BANNING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92220-4823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-849-1950
-----------------------------------------------------
Fax | 951-849-0080
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 20133
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------