MEDICARE: MS. FADERERA ADETOLA SANDA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		CA

General Provider Information

NPI Number	:	1194650788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. FADERERA ADETOLA SANDA

Provider Business Mailing Address
First Line	:	10976 SALINAS WAY
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-2019
Country	:	US
Telephone Number	:	310-359-4810
Fax Number	:

Provider Business Practice Location Address
First Line	:	1196 THIRD AVE
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91911-3131
Country	:	US
Telephone Number	:	619-427-4661
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2026
Last Update Date	:	06/15/2026

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