Healthcare Provider Details

I. General information

NPI: 1740786284
Provider Name (Legal Business Name): KRISTY LEU HUTPUTTANASIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W LA VETA AVE STE 360
ORANGE CA
92868-4300
US

IV. Provider business mailing address

1010 W LA VETA AVE STE 360
ORANGE CA
92868-4300
US

V. Phone/Fax

Practice location:
  • Phone: 714-245-0492
  • Fax: 714-245-0494
Mailing address:
  • Phone: 714-245-0492
  • Fax: 714-245-0494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number818199
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95008450
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: