Provider Demographics
NPI:1447819511
Name:SORMILLON, MARK VINCENT (RN)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:VINCENT
Last Name:SORMILLON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 PLAYA DR UNIT 227
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-2940
Mailing Address - Country:US
Mailing Address - Phone:310-953-1247
Mailing Address - Fax:
Practice Address - Street 1:10201 MISSION GORGE RD STE O
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-3040
Practice Address - Country:US
Practice Address - Phone:310-953-1247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95166326163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult