Healthcare Provider Details

I. General information

NPI: 1164220265
Provider Name (Legal Business Name): CHRISTINA MARIE KHODAVANDI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17150 NEWHOPE ST
FOUNTAIN VALLEY CA
92708-4250
US

IV. Provider business mailing address

17150 NEWHOPE ST
FOUNTAIN VALLEY CA
92708-4250
US

V. Phone/Fax

Practice location:
  • Phone: 714-751-5805
  • Fax:
Mailing address:
  • Phone: 714-751-5824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN95221814
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: