Healthcare Provider Details

I. General information

NPI: 1346603248
Provider Name (Legal Business Name): LAUREN DEWALT AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 KILROY AIRPORT WAY STE 100
LONG BEACH CA
90806-6818
US

IV. Provider business mailing address

4729 E BLUE BIRD AVE
ORANGE CA
92869-1918
US

V. Phone/Fax

Practice location:
  • Phone: 562-527-7600
  • Fax:
Mailing address:
  • Phone: 949-293-1456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95006348
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number835264
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: