Provider Demographics
NPI:1659785020
Name:SANDERS, DOMINIQUE (PMHNP, RN, MSN)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:SANDERS
Suffix:
Gender:F
Credentials:PMHNP, RN, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9431 HAVEN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5879
Mailing Address - Country:US
Mailing Address - Phone:725-234-2215
Mailing Address - Fax:281-954-0056
Practice Address - Street 1:9431 HAVEN AVE STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5879
Practice Address - Country:US
Practice Address - Phone:725-234-2215
Practice Address - Fax:281-954-0056
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA828301163WC0400X
CA95011218363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC0400XNursing Service ProvidersRegistered NurseCase Management