Provider Demographics
NPI:1063174290
Name:BAE, SANDRA YONGSEON (RNFA)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:YONGSEON
Last Name:BAE
Suffix:
Gender:F
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26107 OAK ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:LOMITA
Mailing Address - State:CA
Mailing Address - Zip Code:90717-3180
Mailing Address - Country:US
Mailing Address - Phone:310-977-9495
Mailing Address - Fax:
Practice Address - Street 1:26107 OAK ST UNIT B
Practice Address - Street 2:
Practice Address - City:LOMITA
Practice Address - State:CA
Practice Address - Zip Code:90717-3180
Practice Address - Country:US
Practice Address - Phone:310-977-9495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA725216163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant