Healthcare Provider Details

I. General information

NPI: 1669642856
Provider Name (Legal Business Name): MARY JEAN VANKRUGEL REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8041 NEWMAN AVE
HUNTINGTON BEACH CA
92647-7034
US

IV. Provider business mailing address

19642 WATERBURY LN
HUNTINGTON BEACH CA
92646-3547
US

V. Phone/Fax

Practice location:
  • Phone: 714-847-4222
  • Fax: 714-842-9843
Mailing address:
  • Phone: 714-968-4662
  • Fax: 714-964-2097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number307374
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: