Healthcare Provider Details

I. General information

NPI: 1013793363
Provider Name (Legal Business Name): LEA D WOOD AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2023
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 W 17TH ST
COSTA MESA CA
92627-4350
US

IV. Provider business mailing address

1305 S PROSPECT AVE
REDONDO BEACH CA
90277-5115
US

V. Phone/Fax

Practice location:
  • Phone: 949-209-8953
  • Fax:
Mailing address:
  • Phone: 832-693-1158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95028155
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: