Basic Information
| Provider Information | |||||||||
| NPI: | 1912033846 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOMA LINDA UNIVERSITY MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25123 DAISY AVE | ||||||||
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| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923543510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092660962 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11234 ANDERSON ST | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923542804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095588514 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | VOLLMER-SANDHOLM | ||||||||
| AuthorizedOfficialFirstName: | MARY JO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PEDIATRIC NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 9095588514 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MSN, RN, CPNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 533452 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.