Healthcare Provider Details

I. General information

NPI: 1104472174
Provider Name (Legal Business Name): DIANA BUSH PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2019
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W TOWN AND COUNTRY RD STE 1232
ORANGE CA
92868-4600
US

IV. Provider business mailing address

1100 W TOWN AND COUNTRY RD STE 1250
ORANGE CA
92868-4633
US

V. Phone/Fax

Practice location:
  • Phone: 714-817-7447
  • Fax:
Mailing address:
  • Phone: 714-817-7447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95021382
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number828188
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: