Healthcare Provider Details

I. General information

NPI: 1235642299
Provider Name (Legal Business Name): LAURA LISA CRISOSTOMO RN, PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2017
Last Update Date: 11/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 E GONZALES RD STE 102
OXNARD CA
93036-8293
US

IV. Provider business mailing address

2220 E GONZALES RD STE 102
OXNARD CA
93036-8293
US

V. Phone/Fax

Practice location:
  • Phone: 805-981-5221
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number778298
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: