Healthcare Provider Details

I. General information

NPI: 1780138198
Provider Name (Legal Business Name): MICHELLE LEA WALDBAUM BSN, RN, CNOR, RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5902 NUGGET CIR
HUNTINGTON BEACH CA
92647-2131
US

IV. Provider business mailing address

5902 NUGGET CIR
HUNTINGTON BEACH CA
92647-2131
US

V. Phone/Fax

Practice location:
  • Phone: 714-951-1469
  • Fax:
Mailing address:
  • Phone: 714-951-1469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95022225
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number95022225
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: