Provider Demographics
NPI:1477537140
Name:SAN BERNARDINO DEPARTMENT OF PUBLIC HEALTH
Entity type:Organization
Organization Name:SAN BERNARDINO DEPARTMENT OF PUBLIC HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORNA
Authorized Official - Middle Name:MAUREEN
Authorized Official - Last Name:NYBERG
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:909-466-5974
Mailing Address - Street 1:10332 CHARWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-3076
Mailing Address - Country:US
Mailing Address - Phone:909-466-5974
Mailing Address - Fax:
Practice Address - Street 1:340 N. MT. VIEW AVE.
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-0001
Practice Address - Country:US
Practice Address - Phone:909-387-6224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11125363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS98841Medicare UPIN