Healthcare Provider Details

I. General information

NPI: 1740069483
Provider Name (Legal Business Name): HYESOOK SONG FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2023
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 EAST COMMONWEALTH AVE. SUITE 100
FULLERTON CA
92832
US

IV. Provider business mailing address

662 E VALENCIA ST
ANAHEIM CA
92805-4764
US

V. Phone/Fax

Practice location:
  • Phone: 714-572-3900
  • Fax:
Mailing address:
  • Phone: 714-688-6410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95025720
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: