Healthcare Provider Details

I. General information

NPI: 1437915378
Provider Name (Legal Business Name): LAURA ELLEN BULATAO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA ELLEN BURNS

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 KINGSDALE AVE
REDONDO BEACH CA
90278-3417
US

IV. Provider business mailing address

1959 KINGSDALE AVE
REDONDO BEACH CA
90278-3417
US

V. Phone/Fax

Practice location:
  • Phone: 310-214-1000
  • Fax:
Mailing address:
  • Phone: 310-214-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95029055
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: