Provider Demographics
NPI:1427427319
Name:BALANDRA, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:BALANDRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 414
Mailing Address - Street 2:
Mailing Address - City:PATTON
Mailing Address - State:CA
Mailing Address - Zip Code:92369-0414
Mailing Address - Country:US
Mailing Address - Phone:909-425-7000
Mailing Address - Fax:
Practice Address - Street 1:3102 E HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:PATTON
Practice Address - State:CA
Practice Address - Zip Code:92369-7813
Practice Address - Country:US
Practice Address - Phone:909-425-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD8486194390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program