Healthcare Provider Details

I. General information

NPI: 1649496811
Provider Name (Legal Business Name): LYDIA IRENE MOORE CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23961 CALLE DE LA MAGDALENA STE 334
LAGUNA HILLS CA
92653-3665
US

IV. Provider business mailing address

584 HIGH DR
LAGUNA BEACH CA
92651-1558
US

V. Phone/Fax

Practice location:
  • Phone: 949-951-6019
  • Fax:
Mailing address:
  • Phone: 949-951-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberNPF7346
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: