Healthcare Provider Details

I. General information

NPI: 1649793571
Provider Name (Legal Business Name): LESLIE EXCONDE REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2017
Last Update Date: 07/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17822 BEACH BLVD STE 400
HUNTINGTON BEACH CA
92647-7510
US

IV. Provider business mailing address

17822 BEACH BLVD STE 400
HUNTINGTON BEACH CA
92647-7510
US

V. Phone/Fax

Practice location:
  • Phone: 714-982-7048
  • Fax: 714-845-9941
Mailing address:
  • Phone: 714-982-7048
  • Fax: 714-845-9941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number757529
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: