Healthcare Provider Details

I. General information

NPI: 1699820878
Provider Name (Legal Business Name): LAURETTE ELBERTA MINAGAWA PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURETTE ELBERTA MOUAT PNP

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RADY CHILDREN'S HOSPITAL AND HEALTH CENTER 3020 CHILDREN'S WAY, MC 5030
SAN DIEGO CA
92123
US

IV. Provider business mailing address

1224 W LEWIS ST
SAN DIEGO CA
92103-1725
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-4003
  • Fax: 858-560-6798
Mailing address:
  • Phone: 619-262-9662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN494701
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: