Provider Demographics
NPI:1154820660
Name:DESATOFF, CRAIG SUNDANCE (LVN)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:SUNDANCE
Last Name:DESATOFF
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32164 EVENING PRIMROSE TRL
Mailing Address - Street 2:
Mailing Address - City:CAMPO
Mailing Address - State:CA
Mailing Address - Zip Code:91906-3158
Mailing Address - Country:US
Mailing Address - Phone:619-572-4715
Mailing Address - Fax:
Practice Address - Street 1:2865 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-2411
Practice Address - Country:US
Practice Address - Phone:619-232-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA257231164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse