Healthcare Provider Details

I. General information

NPI: 1306759253
Provider Name (Legal Business Name): ANDREA BERENISSE LEON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 W 19TH ST STE F
COSTA MESA CA
92627-3536
US

IV. Provider business mailing address

745 W 19TH ST STE F
COSTA MESA CA
92627-3536
US

V. Phone/Fax

Practice location:
  • Phone: 949-574-0210
  • Fax:
Mailing address:
  • Phone: 949-574-0210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberF09260854
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: