Healthcare Provider Details

I. General information

NPI: 1548565740
Provider Name (Legal Business Name): ASHA JENISE WILBORN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2011
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 W STEWART DR STE 410
ORANGE CA
92868-3855
US

IV. Provider business mailing address

12900 PARK PLAZA DRIVE STE 150
CERRITOS CA
90703
US

V. Phone/Fax

Practice location:
  • Phone: 714-639-9401
  • Fax: 714-639-4105
Mailing address:
  • Phone: 562-282-4027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number625834
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number20529
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: