Healthcare Provider Details

I. General information

NPI: 1063296002
Provider Name (Legal Business Name): AUTUMN NOELLE TODOROVICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUTUMN NOELLE BENNINGTON

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6328 MOUNT RIPLEY DR
CYPRESS CA
90630-4029
US

IV. Provider business mailing address

6328 MOUNT RIPLEY DR
CYPRESS CA
90630-4029
US

V. Phone/Fax

Practice location:
  • Phone: 714-851-0129
  • Fax:
Mailing address:
  • Phone: 714-851-0129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number95170136
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: