Healthcare Provider Details

I. General information

NPI: 1215522461
Provider Name (Legal Business Name): LAURICE EVETTE HAYCRAFT MSN, RN, APRN, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2021
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 MAGNOLIA AVE #2F
CORONA CA
92879
US

IV. Provider business mailing address

6850 BOEING AVE
FONTANA CA
92336
US

V. Phone/Fax

Practice location:
  • Phone: 951-356-5414
  • Fax:
Mailing address:
  • Phone: 419-870-1888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95016580
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95065093
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: