Healthcare Provider Details

I. General information

NPI: 1902101090
Provider Name (Legal Business Name): ANGELA JIHYE SONG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2011
Last Update Date: 08/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W LA VETA AVE STE 200
ORANGE CA
92868-4301
US

IV. Provider business mailing address

1010 W LA VETA AVE STE 200
ORANGE CA
92868-4301
US

V. Phone/Fax

Practice location:
  • Phone: 714-835-1800
  • Fax: 714-975-7433
Mailing address:
  • Phone: 714-835-1800
  • Fax: 714-975-7433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number19038
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number707308
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: