Healthcare Provider Details

I. General information

NPI: 1073767901
Provider Name (Legal Business Name): PATRICIA TULLY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2008
Last Update Date: 11/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868-3201
US

IV. Provider business mailing address

PO BOX 54778
LOS ANGELES CA
90054-0778
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-8068
  • Fax: 714-456-2979
Mailing address:
  • Phone: 714-456-8068
  • Fax: 714-456-2979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP18628
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN563494
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: