Healthcare Provider Details

I. General information

NPI: 1871199679
Provider Name (Legal Business Name): SHERISSE SOFIA PUATU DNP, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1617 WESTCLIFF DR STE 205
NEWPORT BEACH CA
92660-5526
US

IV. Provider business mailing address

8013 CANTERBURY WAY
BUENA PARK CA
90620-2020
US

V. Phone/Fax

Practice location:
  • Phone: 949-432-4730
  • Fax:
Mailing address:
  • Phone: 562-413-6086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95015137
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: