Provider Demographics
NPI:1508230244
Name:KAZIM, SANDRA DAWN (NP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:DAWN
Last Name:KAZIM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:964 JUNIPERO DR
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5839
Mailing Address - Country:US
Mailing Address - Phone:714-442-5094
Mailing Address - Fax:
Practice Address - Street 1:200 W CENTER STREET PROMENADE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-3960
Practice Address - Country:US
Practice Address - Phone:714-712-9559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA335697363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner