Healthcare Provider Details

I. General information

NPI: 1114469111
Provider Name (Legal Business Name): ANISSA ELLEN SPADA NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2016
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 E 1ST ST STE 100
SANTA ANA CA
92705-4086
US

IV. Provider business mailing address

2010 E 1ST ST STE 100
SANTA ANA CA
92705-4086
US

V. Phone/Fax

Practice location:
  • Phone: 714-556-7246
  • Fax: 714-556-7247
Mailing address:
  • Phone: 714-556-7246
  • Fax: 714-556-7247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9500139
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95005139
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number95005139
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: