Basic Information
Provider Information | |||||||||
NPI: | 1265613574 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALDEN | ||||||||
FirstName: | SANDRA | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN, MSN, PHN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 28776 CALLE VIS | ||||||||
Address2: |   | ||||||||
City: | LAGUNA NIGUEL | ||||||||
State: | CA | ||||||||
PostalCode: | 926777464 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9493375579 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1725 W 17TH ST | ||||||||
Address2: |   | ||||||||
City: | SANTA ANA | ||||||||
State: | CA | ||||||||
PostalCode: | 927062316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7148347763 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2007 | ||||||||
LastUpdateDate: | 11/15/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC1500X | RN325258 | CA | Y |   | Nursing Service Providers | Registered Nurse | Community Health |
No ID Information.