Healthcare Provider Details

I. General information

NPI: 1528289394
Provider Name (Legal Business Name): LILIA VASHTI KNUDTSON NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LILIA VASHTI HERRERA NURSE PRACTITIONER

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 SOUTH MAIN ST
ORANGE CA
92868
US

IV. Provider business mailing address

3329-A EAST LOCHLEVEN LN
ORANGE CA
92869
US

V. Phone/Fax

Practice location:
  • Phone: 714-771-8000
  • Fax: 714-744-8630
Mailing address:
  • Phone: 714-639-4101
  • Fax: 714-744-8630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN217087
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: