Healthcare Provider Details

I. General information

NPI: 1053025239
Provider Name (Legal Business Name): LAURENE BANDOLIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. LAURENE SANDOVAL

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W TOWN AND COUNTRY RD STE 1300
ORANGE CA
92868-4654
US

IV. Provider business mailing address

22885 HILTON HEAD DR UNIT 263
DIAMOND BAR CA
91765-4415
US

V. Phone/Fax

Practice location:
  • Phone: 855-434-7763
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95036098
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95022508
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: