Healthcare Provider Details

I. General information

NPI: 1154535136
Provider Name (Legal Business Name): LORRAINE SUSAN ROBERSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LORRAINE SUSAN DOMINGUEZ NP

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9939 MAGNOLIA AVE STE C
RIVERSIDE CA
92503-3528
US

IV. Provider business mailing address

24425 PERIWINKLE WAY
LAKE ELSINORE CA
92532-2733
US

V. Phone/Fax

Practice location:
  • Phone: 951-354-2229
  • Fax:
Mailing address:
  • Phone: 951-275-3704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number17087
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: