Healthcare Provider Details

I. General information

NPI: 1790201655
Provider Name (Legal Business Name): ANDREA BEATTY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 08/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 SUPERIOR AVE STE 1
NEWPORT BEACH CA
92663-2723
US

IV. Provider business mailing address

1419 SUPERIOR AVE STE 1
NEWPORT BEACH CA
92663-2723
US

V. Phone/Fax

Practice location:
  • Phone: 949-650-0587
  • Fax: 949-631-8155
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95005968
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: