Healthcare Provider Details

I. General information

NPI: 1720700503
Provider Name (Legal Business Name): DENISE BEDOLLA FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2022
Last Update Date: 01/15/2023
Certification Date: 01/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S MAIN ST
CORONA CA
92882-3420
US

IV. Provider business mailing address

36721 AMATEUR WAY
BEAUMONT CA
92223-8118
US

V. Phone/Fax

Practice location:
  • Phone: 951-737-4343
  • Fax:
Mailing address:
  • Phone: 760-792-3142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95022554
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: