Provider Demographics
NPI:1912658782
Name:PRIME, SANDRA NICOLE
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:NICOLE
Last Name:PRIME
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 1:442 F ST APT C4
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-3739
Mailing Address - Country:US
Mailing Address - Phone:626-268-7897
Mailing Address - Fax:
Practice Address - Street 1:430 F ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-3711
Practice Address - Country:US
Practice Address - Phone:619-420-3620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA911-87726-04Medicaid