Healthcare Provider Details

I. General information

NPI: 1588470074
Provider Name (Legal Business Name): GRACE-AILEEN LIZARDO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 THE CITY DR S
ORANGE CA
92868-3205
US

IV. Provider business mailing address

331 THE CITY DR S
ORANGE CA
92868-3205
US

V. Phone/Fax

Practice location:
  • Phone: 714-935-8014
  • Fax:
Mailing address:
  • Phone: 714-935-8014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number527386
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number527386
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: