Healthcare Provider Details

I. General information

NPI: 1194598946
Provider Name (Legal Business Name): MS. LAURA MAE LORENZANA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2023
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12064 COUNTRYSIDE DR
FONTANA CA
92337-0780
US

IV. Provider business mailing address

12064 COUNTRYSIDE DR
FONTANA CA
92337-0780
US

V. Phone/Fax

Practice location:
  • Phone: 909-213-6138
  • Fax:
Mailing address:
  • Phone: 909-213-6138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1196771
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: