Provider Demographics
NPI:1407211592
Name:CARDONA, VANIKA
Entity Type:Individual
Prefix:
First Name:VANIKA
Middle Name:
Last Name:CARDONA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VANICA
Other - Middle Name:AIDA
Other - Last Name:LONGSWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 E GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0911
Mailing Address - Country:US
Mailing Address - Phone:909-580-3144
Mailing Address - Fax:909-580-2165
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-3144
Practice Address - Fax:909-580-2165
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30547167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician