Healthcare Provider Details

I. General information

NPI: 1932559853
Provider Name (Legal Business Name): TERESA BOLO NOVALES NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 12/01/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 REDONDO AVE FL 3
LONG BEACH CA
90806-2325
US

IV. Provider business mailing address

4143 AVENIDA MADRID
CYPRESS CA
90630-3405
US

V. Phone/Fax

Practice location:
  • Phone: 562-256-2900
  • Fax:
Mailing address:
  • Phone: 714-220-7466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95005760
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95005760
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number611372
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: