Healthcare Provider Details

I. General information

NPI: 1750444089
Provider Name (Legal Business Name): TERESA LOUISE CHARLESWORTH RNC, MSN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N MAIN ST
SANTA ANA CA
92701-2321
US

IV. Provider business mailing address

6888 LEILANI LN
CYPRESS CA
90630-5718
US

V. Phone/Fax

Practice location:
  • Phone: 714-541-6815
  • Fax: 714-541-8032
Mailing address:
  • Phone: 714-657-0657
  • Fax: 714-657-0657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number429304
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10422
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: