Healthcare Provider Details

I. General information

NPI: 1154495620
Provider Name (Legal Business Name): LAURA A BOOTH RN, MS, CNS, ANP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 LA JOLLA VILLAGE DR
SAN DIEGO CA
92161-0002
US

IV. Provider business mailing address

3350 LA JOLLA VILLAGE DR
SAN DIEGO CA
92161-0002
US

V. Phone/Fax

Practice location:
  • Phone: 858-642-6277
  • Fax:
Mailing address:
  • Phone: 858-642-6277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number16389
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number2476
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number531287
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: