Healthcare Provider Details

I. General information

NPI: 1508399353
Provider Name (Legal Business Name): BERENIS AMEZCUA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2017
Last Update Date: 04/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 W LINCOLN AVE SUITE 105
ANAHEIM CA
92805-2936
US

IV. Provider business mailing address

303 W LINCOLN AVE SUITE 105
ANAHEIM CA
92805-2936
US

V. Phone/Fax

Practice location:
  • Phone: 714-922-4100
  • Fax: 714-956-2748
Mailing address:
  • Phone: 714-922-4100
  • Fax: 714-956-2748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95101936
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: