Provider Demographics
NPI:1467792283
Name:MOUA, SANDY
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:
Last Name:MOUA
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 1:37586 COLLEGE DR
Mailing Address - Street 2:UNIT 101
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-2926
Mailing Address - Country:US
Mailing Address - Phone:951-233-5985
Mailing Address - Fax:
Practice Address - Street 1:58945 BUSINESS CENTER DR
Practice Address - Street 2:SUITE D
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-7307
Practice Address - Country:US
Practice Address - Phone:760-228-9657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-15
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36344167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician